Saint Louis, MO Candidates need to be able to work in the City or State specified – Telecommute
Utilization Management Nurse – 100% Virtual -Missouri
Saint Louis, MO 63101
ProgenyHealth is a leading provider of care management solutions for premature and medically complex newborns. Our program promotes appropriate utilization, improves access, educates family members and reduces costs.
Our team of neonatologists, pediatricians, and NICU nurses provide continuity of care in collaboration with providers from hospital to home and throughout the first year of life.
Utilization Management / Clinical Care Nurses coordinate overall member care, from pre-admission, continued stay (concurrent review) and any outpatient services utilizing a pro-active, evidence-based decision making process that is physician sensitive and attaining quality outcomes for the members. The clinical care nurse serves as a nurse reviewer for admissions, lengths of stay and a facilitator for discharge planning. This position functions as a liaison between the providers, hospitals and health plans. Responsible for the implementation of client-specific contracted polices, managed care policies and must be very knowledgeable about benefits, criteria and guidelines used for reviews. Must be adept at identifying and referring potential quality of care issues to the Medical Director, client and/or appropriate staff.
Initiating the continuum of care process for neonatal admissions.
Interacting telephonically and in writing with hospital staff to collect clinical information for newborns in intensive care nurseries in order to facilitate medical necessity determinations.
Coordinating discharge planning needs for newborns being discharged from intensive care nurseries.
Authorization of all services requiring prior authorization, based upon health plan specific service agreements
Review of all services (readmissions and elective procedures) for first year of life
Documenting all activities in the electronic medical record.
Registered Nurse (RN) with a current, unrestricted license is required
Three or more years of clinical experience as a NICU nurse is required.
Five or more years of experience working in a concurrent review or discharge planning role within a health plan or an acute facility is required.
Experience with Interqual and/or MCG is required.
Experience with URAC and/or NCQA standards is preferred.
Experience with data entry into a database or EHR required. Must have strong computer skills.
Excellent communication skills and organizational ability is required.
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, telephone etiquette and maintain positive communication at all times.
Must have commitment to excellence in customer service
Our team is our most important asset. some of the benefits we offer our team are:
401K with company match
Medical and dental benefits
Long Term Disability
Paid Time Off
Business Casual Work environment
Team orientated events throughout the year
Role specific – partial or full telecommuting (after training period)
Medical & Health , Nursing