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This job applies clinical expertise as well as knowledge of utilization and discharge planning criteria to review medical information of prior hospitalized patients that are being reviewed via the regulatory audit process. Identifies issues and problems such as inappropriate admissions and non-acute hospital days which may adversely impact quality patient care, appropriate utilization of hospital resources, or optimal financial reimbursement to the company.
Functions as a liaison with the department Vice President/Manager of Regulatory Audits and ensures compliance with regulations and alternative level of care options affecting the company's revenue as it relates to all medical necessity audits. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the
. This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities.
Contents are subject to change at the company's discretion. Education Required - Registered Nurse Diploma Preferred - Associate's or Bachelor's degree in Nursing Work Experience Required - 3 years Hospital based experience in the delivery of patient care as an RN. Experience in Case Management, Utilization Review and/or Discharge Planning .either in the Acute Care environment or Managed Care environment.
Experience responding to change positively and work calmly as well as efficiently in high pressure situations. Experience functioning independently and working well within a team setting. Preferred - Experience in Appeal/Denial Management Certifications Required - Current Registered Nurse (RN) License in the state of practice Preferred - Certification in Case Management (CCM) or Certified Professional in Utilization Review, Utilization Management or Health Care Management (CPUR, CPUM, and CPHM) Knowledge Skills and Abilities (KSAs) Must have computer skills and dexterity required for data entry and retrieval of patient information.
Must be proficient with Windows-style applications, various software packages specific to role and keyboard. Effective verbal and written communication skills and the ability to present information clearly and professionally to varying levels of individuals throughout the patient care process Strong financial skills Job Duties Validates a specific level of care and evaluates against registered level of care to determine which medical necessity level of care is required.
Reviews all incoming denial and informational requests from regulatory and other agencies in respect to clinical medical necessity determinations. Identifies, plans, and coordinates aspects of medical necessity reviews with others as necessary. Maintains current knowledge of third party payer and government requirements related to job functions.
Maintains minimum standards for licensure and strives for professional/personal development. Adapts behavior to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style. Other related duties as required.
The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.
Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards. This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns.
The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status. Physical and Environmental Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the
. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. (Constantly: activity or condition exists 2/3 or more of the time) to move objects.
are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.
NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible. Mechanical lifting devices (carts, dollies, etc.) or team lifts should be utilized. Must be able to stoop, bend, reach and grab with arms and hands, manual dexterity.
Must be able to stand for prolonged periods of time. Must be able to work a flexible work schedule (e.g. 24/7, weekend, holiday, on call availability). Must be able to travel throughout and between facilities.
Duties performed routinely require exposure to blood, body fluid and tissue. The incumbent works in a patient care area; works in an area where patients enter; works directly with patients; and/or works with specimens that could contain diseases. There may be an occupational risk for exposure to all communicable diseases.
Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste. The risk level of exposure may increase depending on the essential job duties of the role. Are you ready to make a difference?
Apply Today! Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website. Please refer to the job description to determine whether the position you are interested in is remote or on-site.
Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New York, Vermont, Washington, and Washington D. C. Ochsner Health endeavors to make our site accessible to all users.
If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or careers@ochsner.org . This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. Ochsner is an equal opportunity employer.
All qualified applicants will receive consideration for employment without regard to any legally protected class, including protected veterans and individuals with disabilities.