Utilization Management NICU Nurse

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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 and outpatient services using proactive, evidence-based decision-making. • 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. • Identify and refer potential quality-of-care issues to the Medical Director, client, 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 according to 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, weekend, and holiday on-call coverage.

🎯 Requirements

• Registered Nurse (RN) with a current, unrestricted license required. • Three or more years of clinical nursing experience in a Level III or Level IV NICU required. • Three or more years of concurrent review or discharge planning experience within a health plan or acute facility strongly preferred. • Willingness to provide occasional weekend and holiday coverage. • Experience with InterQual and/or MCG preferred. • Experience with URAC and/or NCQA standards preferred. • Experience entering data into a database or EHR required. • Strong computer skills. • Self-motivated and willing to learn multiple tasks. • Well organized and able to prioritize tasks. • Accuracy in spelling and documentation. • Ability to perform job functions autonomously and be a self-starter. • Excellent interpersonal skills and telephone etiquette. • Positive communication at all times. • 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