Utilization Management NICU Nurse

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee comprehensive member care from pre-admission through ongoing stay, concurrent reviews, and outpatient services.

• Function as a nurse reviewer for admissions and lengths of stay.

• Assist in discharge planning processes.

• Serve as a communication link between healthcare providers, hospitals, and health plans.

• Execute client-specific contracted policies along with managed care policies.

• Employ benefits, criteria, and guidelines for evaluations.

• Detect and refer potential quality-of-care concerns to the Medical Director, client, and/or relevant staff.

• Initiate the continuum-of-care process for neonatal admissions.

• Communicate via phone and in writing with hospital personnel to gather clinical information for newborns in intensive care nurseries.

• Support medical necessity evaluations.

• Coordinate discharge planning requirements for newborns exiting intensive care nurseries.

• Authorize services that require prior approval in accordance with health-plan-specific agreements.

• Review readmissions and elective procedures occurring within the first year of life.

• Record all activities in the electronic medical record.

• Provide occasional evening and/or weekend on-call support.

⛳️ Requirements

• A current, unrestricted Registered Nurse (RN) license is mandatory.

• A minimum of three years of clinical experience as a nurse in a Level III or Level IV NICU is essential.

• At least three years of experience in a concurrent review or discharge planning capacity within a health plan or acute facility is highly preferred.

• Willingness to provide weekend and holiday coverage on occasion is required.

• Familiarity with Interqual and/or MCG is preferred.

• Knowledge of URAC and/or NCQA standards is preferred.

• Experience in data entry into a database or EHR is required.

• Proficient computer skills are necessary.

• Must be self-driven and eager to learn multiple tasks.

• Strong organizational skills and the ability to prioritize tasks effectively are required.

• Accuracy in spelling and documentation is essential.

• Ability to work autonomously and take initiative is necessary.

• Exceptional interpersonal skills and telephone etiquette are required.

• Must maintain positive communication at all times.

• A commitment to excellence in customer service is expected.

🏝️ Benefits

• Paid Time Off

• Paid Parental Leave

• Medical, dental, and vision benefits

• 401K with company match

• Short- and Long-Term Disability

• Group Life Insurance

• Tuition reimbursement

• Professional development opportunities

• Business Casual work environment