Utilization Management NICU Nurse

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 12%

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ProgenyHealth, LLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

🏥 Healthcare

⚕️ Healthcare Insurance

☁️ SaaS

Healthcare • Healthcare Insurance • SaaS

ProgenyHealth, LLC is a company focused on transforming healthcare for women, infants, and families through its integrated Maternity and NICU Care Management solutions. With over 20 years of experience, ProgenyHealth provides a comprehensive care management solution to address the maternity and NICU challenges faced by modern health plans. By identifying risks early, the company aims to prevent preterm births, NICU stays, and complications during pregnancy and after delivery. ProgenyHealth operates as a trusted partner for health plans, overseeing a full maternal and infant care continuum, creating lasting relationships, and optimizing maternal and infant healthcare economics. The company also helps solve non-clinical social drivers impacting maternal and infant health, ensuring equitable, standardized, and predictable family care.

📋 Description

• Coordinate overall member care from pre-admission through continued stay/concurrent review and outpatient services • Serve as a nurse reviewer for admissions and lengths of stay • Facilitate discharge planning • Act as a liaison between providers, hospitals, and health plans • Implement client-specific contracted policies and managed care policies • Apply benefits, criteria, and guidelines for reviews • Identify and refer potential quality-of-care issues to the Medical Director, client, and/or appropriate staff • Initiate the continuum-of-care process for neonatal admissions • Interact by telephone and in writing with hospital staff to collect clinical information for newborns in intensive care nurseries • Facilitate medical necessity determinations • Coordinate discharge planning needs for newborns leaving intensive care nurseries • Authorize services requiring prior authorization based on health-plan-specific service agreements • Review readmissions and elective procedures during the first year of life • Document all activities in the electronic medical record • Provide occasional evening and/or weekend on-call coverage

🎯 Requirements

• Registered Nurse (RN) with a current, unrestricted license is required • Three or more years of clinical experience as a nurse in a Level III or Level IV NICU is required • Three or more years of experience working in a concurrent review or discharge planning role within a health plan or an acute facility is strongly preferred • Must be willing to provide weekend and holiday coverage occasionally • Experience with Interqual and/or MCG is preferred • Experience with URAC and/or NCQA standards is preferred • Experience with data entry into a database or EHR required • Must have strong computer skills • Must be self-motivated and willing to learn multiple tasks • Must be well organized and able to prioritize tasks • Must demonstrate accuracy in spelling and documentation • Ability to perform job functions with autonomy and be a self-starter • Must possess excellent interpersonal skills and telephone etiquette • Must maintain positive communication at all times • Must have commitment to excellence in customer service

🏖️ Benefits

• Paid Time Off • Paid Parental Leave • Medical, dental, vision benefits • 401K with company match • Short- and Long-Term Disability • Group Life Insurance • Tuition reimbursement • Professional development opportunities • Business Casual work environment

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