RN- Utilization Management- Remote

Ochsner Health•New Orleans, LA

1d•Remote

About The Position

The Utilization Management Registered Nurse determines psychosocial, environmental, family, and economic factors that may affect patients. The RN confirms that the physician has placed a clear, specific care-setting order and applies hospital-approved medical necessity criteria to review admissions, levels of care, and continued stays. The RN documents reviews in the hospital-approved data set and, when appropriate, discusses alternative care options with emergency department, admitting, or attending physicians. The role serves as a liaison and communicator among patients, caregivers, multidisciplinary team members, post-acute care providers, and third-party payers. The position manages assigned patients’ care through the healthcare system according to individual needs and manages planning for patients’ movement through the system. It includes pre-admission, admission, and continued-stay activities, maintaining communication with appropriate parties, and working with managed-care and other third-party payers to obtain financial certification, support appropriate reimbursement, and minimize denials. The role also requires compliance with applicable laws, accreditation standards, regulatory requirements, and the employer’s Compliance & Privacy Program and Standards of Conduct. The position is identified as remote, subject to the employer’s restrictions on remote work for residents working from certain states and Washington, D.C. The role may require a flexible schedule, including availability for 24/7 coverage, weekends, holidays, or on-call work. Physical demands are classified as Light Work, with prolonged sitting, manual dexterity, and the ability to stoop, bend, reach, and grasp. The healthcare setting carries potential exposure to blood, body fluids, tissue, communicable diseases, hazardous medications, and hazardous waste.

Requirements

Registered Nurse diploma or equivalent.
At least 1 year of hospital-based experience delivering patient care.
Current RN license in the state of practice.
Experience functioning independently and working effectively within a team.
Ability to respond positively to change and work calmly and efficiently in high-pressure situations.
Computer skills and dexterity for entering and retrieving patient information; proficiency with Windows-style applications and keyboard use.
Effective verbal and written communication skills, including the ability to present information clearly and professionally to people at varying levels throughout the patient-care process.
Excellent conflict-resolution skills.
Objectivity, strong ethical principles, professionalism, a strong work ethic, energy, and creativity.
Ability to meet the physical demands of Light Work, including prolonged sitting and manual dexterity; ability to stoop, bend, reach, and grasp.
Ability to work a flexible schedule, such as 24/7 availability, weekends, holidays, or on-call availability.

Nice To Haves

Experience in Case Management or Utilization Review.
Business and financial knowledge and understanding of healthcare delivery systems.

Responsibilities

Perform pre-admission, admission, and continued-stay review activities.
Confirm a clear, specific physician order for the care setting and apply hospital-approved medical necessity criteria to review admissions, levels of care, and continued stays.
Document completed reviews in the hospital-approved data set.
Discuss alternative care options with emergency department, admitting, or attending physicians when appropriate.
Maintain open communication with appropriate parties, including patients, caregivers, multidisciplinary team members, post-acute care providers, and third-party payers.
Manage planning for patients’ movement through the healthcare system.
Interact proactively with managed-care and third-party payers to obtain financial certification, support appropriate reimbursement, and minimize reimbursement denials.
Manage assigned patients’ care through the healthcare system based on their individual needs.
Remain knowledgeable about and comply with applicable federal, state, and local laws, accreditation standards, and regulatory agency requirements.
Comply with the employer’s Compliance & Privacy Program and Standards of Conduct, and immediately report known or suspected unethical or questionable conduct and safety, privacy, or other compliance concerns.
Maintain licensure standards and pursue professional and personal development.
Support the values of Service Excellence, Teamwork, and Integrity.
Perform additional duties as assigned or required.