Director - Utilization Review - South Louisiana

We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate.  We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways. 

At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters.  Come make a difference at Ochsner Health and discover your future today! 

This job is responsible for upholding the strategic vision, direction and overall accountability for the Utilization Management Department. Develops, implements and monitors strategies for cost reduction and utilization management. Implements and leads all regulations related to utilization management and revenue cycle operations. Provides oversight/administration of the standard operating policies and procedures required for the success in the division. Required to independently make daily operational management, decisions that could seriously affect the overall Revenue Cycle division and/or company's financial objectives, performance objectives and strategic results.

Education

Required – Bachelor’s degree in nursing

Preferred – Master’s degree in nursing

Work Experience

Required – 7 years of case management experience in a managed care or acute care setting, including 3 years of leadership experience

Certifications

Required – Registered Nurse (RN) license in the state of practice

Preferred – Certified Case Manager (CCM), Accredited Case Manager (ACM), or Certified Professional in Healthcare Management (CPHM)

Knowledge Skills and Abilities (KSAs)

• Must have computer skills for associated software applications (Excel, Word, email functions) and dexterity required for data entry and retrieval of information.

• Effective verbal and written communication skills and the ability to present information clearly and professionally.

• Must be proficient with Windows-style applications, various software packages specific to role and keyboard.

• Strong interpersonal skills.

• Excellent communication skills and abilities to work collaboratively with Executives, leadership, and support staff.

• Ability to anticipate issues that adversely impact the function of the department and use deductive reasoning skills to solve problems.

• Excellent judgment, organization skills, group facilitation skills, decision making and delegating skills.

• Must have a positive, professional attitude, foster teamwork and exhibits excellent self-direction, good judgement in handling difficult situations and good organizational, time management, interpersonal and conflict resolution skills.

Job Duties

• Lead and directs Utilization Review (UR) staff and functions, including staffing, staff engagement, training, purchasing, departmental budgeting, and labor management.

• Assists in developing policies, standard operating procedures and programs that incorporate best practices and ensure effective, compliant utilization reviews.

• Implements and leads regulations for utilization management, including admission and continued stay medical necessity criteria review, payer authorization, denials management, and ensures adherence to the established utilization management plan.       

• Manages and monitors performance to ensure reviews are completed accurately and are appropriately reviewed with Providers in a timely manner.

• Manages the completion of retro-active audit reviews to identify escalation issues regarding Providers, other facility issues, individual utilization review staff skills, payor-based concerns and to provide teaching material for UR staff.

• Analyzes and reports utilization trends, patterns and impacts to the organization and make suggestions for improvement.

• Appropriately escalates payor-based issues on both individual cases and identifies practice pattern issues to ensure appropriate coverage of patient's stay.

• 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