RN Recovery Nurse Specialist – Utilization Management

This is a fully remote position, open to applicants in Louisiana.

📋 Description

• Utilize clinical expertise and discharge-planning criteria to assess medical data from previously hospitalized patients undergoing regulatory audits.

• Detect inappropriate admissions and non-acute hospital days that impact patient care quality, resource utilization, and financial reimbursement.

• Collaborate with the Vice President/Manager of Regulatory Audits within the department.

• Ensure adherence to regulations and alternative care levels that influence company revenue during medical-necessity audits.

• Confirm levels of care and assess them against registered levels to establish necessary medical-necessity care.

• Examine denial and informational requests from regulatory and other agencies concerning clinical medical-necessity determinations.

• Identify, strategize, and coordinate medical-necessity reviews with relevant parties.

• Stay updated on third-party payer and government requirements.

• Tailor communication and service explanations to patient populations while maintaining privacy and securing permissions.

• Uphold licensure standards and engage in professional development.

• Ensure compliance with federal, state, and local laws, as well as accreditation standards and regulatory requirements.

• Report any known or suspected unethical behavior and concerns regarding patient, employee, privacy, or compliance matters.

⛳️ Requirements

• Diploma in Registered Nursing.

• Valid Registered Nurse (RN) License in the state of practice.

• Minimum of 3 years of hospital-based experience providing patient care as an RN.

• Experience in Case Management, Utilization Review, and/or Discharge Planning within an Acute Care or Managed Care setting.

• Proven ability to respond positively to change and maintain composure in high-pressure situations.

• Experience working independently and effectively within a team environment.

• Proficient computer skills and dexterity for data entry and retrieval of patient information.

• Competence with Windows-style applications, role-specific software, and keyboard usage.

• Strong verbal and written communication abilities.

• Solid financial skills.

• Capacity to work a flexible schedule, including 24/7, weekends, holidays, and on-call duties.

• Willingness to travel between and within facilities.

• Ability to meet medium-work physical demands, including standing for long periods and performing tasks requiring bending, reaching, grabbing, and manual dexterity.

• Capability to work in healthcare settings with potential exposure to blood, body fluids, tissues, communicable diseases, hazardous medications, and hazardous waste.

🏝️ Benefits

• Full-time employment.

• Opportunities for professional and personal development.

• Reasonable accommodations for qualified individuals with disabilities.

• Equal opportunity employment.