Utilization Management Nurse

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.

The Utilization Management Associate (UMA) will assist the ProgenyHealth UM program by providing administration support to the Utilization Review department. This includes: intake, screening and precertification of appropriate healthcare services. They will also be responsible for assisting the Clinical Care Nurses with clerical tasks associated with discharge planning/utilization review functions. The UMA will report to the Supervisor of Utilization Review. Hours for this job will be Monday through Friday 10:00am to 6:30pm EST, with flexibility as needed.

Monitor Member eligibility Perform outreach calls to hospitals for follow-up clinical information and discharge info Process new admissions: this includes update of patient demographics; create new case in BabyTrax®; document new case in client system; assign Clinical Care Nurse Communicate verbally and/or written prior authorizations based on client specifications Receive incoming calls for UM and refer to appropriate staff member Adheres to policies, procedures and regulations to ensure compliance and patient safety. Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements Provides additional support and project work within the various Care Management areas of accountability as needed.