RN Recovery Nurse Specialist – Utilization Management

🔥 13 hours ago

⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Ochsner Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1942

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 Non-profit

💰 Grant on 2023-07

Healthcare • Healthcare Insurance • Non-profit

Ochsner Health is a comprehensive healthcare system dedicated to delivering health services to the people of Louisiana, Mississippi, and the Gulf South. Its mission is to serve, heal, lead, educate, and innovate in healthcare. As the largest academic medical center in Louisiana, Ochsner focuses on a clinically-integrated research program aimed at improving community wellness and educating future healthcare leaders. They offer a variety of services, including primary care, urgent care, women's and men's health, digital medicine, and specialized treatments such as cancer care, heart and vascular services, transplants, and more. Ochsner also emphasizes community engagement through partnerships, education, and outreach programs, while fostering an inclusive environment. They are committed to accessibility, patient stories, and transparency in billing and insurance information. Ochsner is a non-profit organization and an equal opportunity employer.

📋 Description

• Apply clinical expertise and utilization/discharge-planning criteria to review medical information from prior hospitalized patients undergoing regulatory audits • Identify inappropriate admissions and non-acute hospital days affecting patient-care quality, hospital-resource utilization, and financial reimbursement • Liaise with the department Vice President/Manager of Regulatory Audits • Ensure compliance with regulations and alternative levels of care affecting company revenue in medical-necessity audits • Validate levels of care and evaluate them against registered levels to determine required medical-necessity care • Review denial and informational requests from regulatory and other agencies regarding clinical medical-necessity determinations • Identify, plan, and coordinate medical-necessity reviews with relevant stakeholders • Maintain current knowledge of third-party payer and government requirements • Adapt communication and service explanations to patient populations while respecting privacy and obtaining permissions • Maintain licensure standards and pursue professional development • Ensure compliance with applicable federal, state, and local laws, accreditation standards, and regulatory requirements • Report known or suspected unethical conduct and patient, employee, privacy, or compliance concerns

🎯 Requirements

• Registered Nurse Diploma • Current Registered Nurse (RN) License in the state of practice • 3 years of hospital-based experience delivering patient care as an RN • Experience in Case Management, Utilization Review and/or Discharge Planning in an Acute Care or Managed Care environment • Experience responding positively to change and working calmly and efficiently in high-pressure situations • Experience functioning independently and working well within a team setting • Computer skills and dexterity for patient-information data entry and retrieval • Proficiency with Windows-style applications, role-specific software packages, and keyboard • Effective verbal and written communication skills • Strong financial skills • Ability to work a flexible schedule, including 24/7, weekends, holidays, and on-call availability • Ability to travel throughout and between facilities • Ability to meet medium-work physical demands, stand for prolonged periods, and stoop, bend, reach, grab, and use manual dexterity • Ability to work in healthcare environments with potential exposure to blood, body fluids, tissue, communicable diseases, hazardous medications, and hazardous waste

🏖️ Benefits

• Full-time employment • Professional/personal development opportunities • Reasonable accommodations for qualified individuals with disabilities • Equal opportunity employment