Job Summary

Company Description

ProgenyHealth is a company specializing in care management solutions for infants in intensive care nurseries. We partner with health plans and employer groups and their neonatal providers to work collaboratively in developing a plan of care specific to the needs of each child. We work with the plans' neonatal providers and families from the moment an infant is admitted to the intensive care nursery, until they are safely transitioned from the hospital through the first year of life.

Our culture and work environment promotes and inspires an active, continuous improvement philosophy in regard to products and services in line with our company mission statement which is as follows:

With passion and a singular focus, we improve the health outcomes of premature and medically complex newborns through provider collaboration and parental engagement.

Job Description

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.



Responsibilities include:

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.

Qualifications

Job Requirements:

Registered Nurse (RN) with a current, unrestricted license is required

Three or more years of clinical experience as a NICU nurse is required

Five (5)+ years 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 or NCQA standards preferred

Data entry skills required.

Must be comfortable with and have good 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.

Additional information

To Apply directly: https://progenyhealth.recruiterbox.com/jobs/fk0ba9

We offer: competitive pay, generous benefits, flexible scheduling, 100% telecommuting with one week of on-site training)

ProgenyHealth is an Equal Opportunity Employer.

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