Utilization Management Nurse Consultant, NICU
Job Description: • Perform concurrent clinical reviews of NICU admissions for special populations, using evidence-based criteria (e.g., InterQual, MCG) • Collaborate with attending providers, case managers, and multidisciplinary teams to coordinate care, facilitate safe transitions, and advocate for optimal outcomes • Ensure medical necessity, appropriateness, and length-of-stay determinations align with contractual, regulatory, and accreditation standards (e.g., Medicaid, CMS, NCQA) • Communicate clinical decisions to providers, member families, and internal stakeholders with empathy and clarity • Identify barriers to care, escalate complex cases, and participate in interdisciplinary rounds as needed • Support discharge planning and transition of care, engaging with families to address social determinants and unique member needs • Maintain accurate, timely documentation in UM systems, ensuring data integrity and compliance • Participate in quality improvement, policy review, and education related to NICU and special populations utilization management • Serve as a clinical resource on NICU care for internal and external partners Requirements: • Active, unrestricted RN license in Louisiana or a compact license • Minimum 5 years of recent clinical experience • Working knowledge of UM review tools (e.g., InterQual, MCG) and regulatory requirements • Strong communication, critical thinking, and family engagement skills • Comfort working with diverse, high-risk member populations and collaborating across disciplines • Ability to work rotating weekends/holidays Benefits: • Affordable medical plan options • 401(k) plan (including matching company contributions) • Employee stock purchase plan • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs • Confidential counseling and financial coaching • Paid time off • Flexible work schedules • Family leave • Dependent care resources • Colleague assistance programs • Tuition assistance • Retiree medical access Apply tot his job