Utilization Management NICU Nurse

ProgenyHealth, LLC

. Coordinate overall member care from pre-admission through continued stay/concurrent review and outpatient services .

Posted 11/10/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in coordinating member care, discharge planning, and clinical reviews within a NICU setting. Proficient in applying managed care policies and ensuring compliance with URAC and NCQA standards.

Highest-signal resume keywords

Registered Nurse (RN) LicenseNICU Clinical ExperienceConcurrent Review ExperienceInterqual and/or MCG ExperienceElectronic Medical Record (EMR) Documentation

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewDischarge PlanningData EntryMedical Necessity DeterminationQuality-of-Care Issue Identification

Soft Skills

Interpersonal SkillsOrganizational SkillsCommunication SkillsSelf-MotivationAttention to Detail

Tools & Technologies

Electronic Health Record (EHR)Database Management

Certifications & Qualifications

Registered Nurse (RN) License

Industry Keywords

Managed Care PoliciesURAC StandardsNCQA StandardsLevel III NICULevel IV NICU

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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