Claims Review Nurse

JOB SUMMARY

The Claims Review Nurse is a full-time role with NeueHealth, dedicated to promoting quality and cost-effective outcomes for the designated population. Working in collaboration with Medical Directors and the clinical team, the Claims Nurse ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria. The Claims Nurse also collects and analyzes utilization data and monitors the quality and appropriate use of services. This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with healthcare providers, patients, and health plans. The Claims Nurse adheres to all standard operating procedures and organizational policies and consistently meets or exceeds established performance benchmarks.

DUTIES & RESPONSIBILITIES

1. Authorization and Review

• Evaluate and process claims and post-service authorization requests for medical procedures, medications, and services based on clinical guidelines such as: Medicare criteria, Medicaid/Medi-Cal criteria, MCG, or Health Plan specific guidelines.
• Utilize clinical knowledge to assess medical necessity and appropriateness of requested services.
• Verify patient eligibility, benefits, and coverage details.

2. Collaboration and Communication

• Serve as a liaison between healthcare providers, patients, and Medical Directors to facilitate the claims review process.
• Communicate authorization decisions to the requesting provider and/or patient in a timely manner.
• Provide detailed explanations of denials or alternative solutions when authorization is not granted.
• Collaborate with the Medical Directors as needed to ensure all information is considered prior to an adverse determination.
• When an adverse determination is rendered, collaborate with the Medical Director to ensure integrity of determination notices based on the quality standards for adverse determinations.
• Comply with federal, state, and health plan specific requirements related to member communication of adverse determinations to include preferred language, mandated readability standard, correct medical criteria is referenced and the appropriate appeal information is provided.

3. Documentation and Compliance

• Accurately document all authorization-related activities in EZ CAP the electronic medical record (EMR) or authorization management system.
• Ensure compliance with federal, state, and health plan specific regulations and guidelines.
• Maintain knowledge of evolving policy and clinical criteria.

4. Quality Improvement

• Identify trends or recurring issues in authorization denials and recommend process improvements.
• Participate in team meetings, training sessions, and audits to ensure high-quality performance.

QUALIFICATIONS

Education:

• Active California license as a (LVN) or Registered Nurse (RN)
• Certification Managed Care Nursing (CMCN) preferred.

Experience:

• Minimum 2 years of claims review nursing experience, in utilization management, case management, or prior authorizations.
• Familiarity with insurance authorization processes, medical billing, and coding (e.g., ICD-10, CPT codes).
• Working knowledge of MCG and CMS guidelines

Skills:

• Strong analytical and critical thinking skills to assess medical necessity.
• Proficient in medical terminology and pharmacology.
• Effective written and verbal communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Highly adaptable to change and self-motivated.

Technology:

• Experience with EMR systems and EZ CAP prior authorization platforms.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook).