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 and outpatient services utilizing proactive, evidence-based decision-making.

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

• Assist in discharge planning processes.

• Serve as a connector between providers, hospitals, and health plans.

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

• Recognize and refer potential quality-of-care concerns to the Medical Director, client, or appropriate personnel.

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

• Communicate by telephone and in writing with hospital personnel to gather clinical data for newborns in intensive care nurseries.

• Facilitate determinations of medical necessity.

• Coordinate discharge planning needs for newborns transitioning out of intensive care nurseries.

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

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

• Document all activities in the electronic medical record.

• Provide occasional on-call coverage during evenings, weekends, and holidays.

⛳️ Requirements

• Current, unrestricted Registered Nurse (RN) license is required.

• A minimum of three years of clinical nursing experience in a Level III or Level IV NICU is required.

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

• Willingness to offer occasional weekend and holiday coverage.

• Familiarity with InterQual and/or MCG is preferred.

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

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

• Strong computer skills are essential.

• Self-motivated and eager to learn multiple tasks.

• Highly organized with the ability to prioritize tasks effectively.

• Accuracy in spelling and documentation is critical.

• Capability to perform job functions independently and be a self-starter.

• Excellent interpersonal skills and telephone etiquette are necessary.

• Maintain positive communication at all times.

• Commitment to providing excellence in customer service.

🏝️ 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