RN Recovery Nurse Specialist - Revenue Cycle Solutions Team - Full Time - Days - Work from Home (Remote)

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 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 Ochsner Health System (OHS). 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 OHS revenue as it relates to all medical necessity audits.

 

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 State of Louisiana Registered Nurse (RN) License

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.

Complies with the Ochsner Health System 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.

Ochsner is an Equal Opportunity Employer. All qualified applicants will rec