RN Recovery Nurse Specialist – Utilization Management

Ochsner Health

. Apply clinical expertise and utilization/discharge-planning criteria to review medical information from prior hospitalized patients undergoing regulatory audits .

Posted 10/9/2026full-timeRemote • Louisiana • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Clinical Utilization Review and Discharge Planning, ensuring compliance with medical necessity regulations while effectively coordinating with stakeholders. Maintains strong communication skills and financial acumen to enhance patient care quality and hospital resource utilization.

Highest-signal resume keywords

Registered Nurse LicenseClinical Utilization ReviewDischarge PlanningCase ManagementEffective Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ExpertiseUtilization ReviewDischarge PlanningPatient CareMedical Necessity AuditsData EntryFinancial SkillsRegulatory ComplianceKnowledge of Third-Party Payer RequirementsMedical Record Review

Soft Skills

AdaptabilityTeam CollaborationCalm Under PressureIndependent FunctioningEffective Communication

Tools & Technologies

Windows ApplicationsRole-Specific Software Packages

Certifications & Qualifications

Registered Nurse Diploma

Industry Keywords

Acute CareManaged CareHealthcare CompliancePatient PrivacyAccreditation Standards

About the role

Key responsibilities & impact

Apply clinical expertise and utilization/discharge-planning criteria to review medical information from prior hospitalized patients undergoing regulatory audits
Identify inappropriate admissions and non-acute hospital days affecting patient-care quality, hospital-resource utilization, and financial reimbursement
Liaise with the department Vice President/Manager of Regulatory Audits
Ensure compliance with regulations and alternative levels of care affecting company revenue in medical-necessity audits
Validate levels of care and evaluate them against registered levels to determine required medical-necessity care
Review denial and informational requests from regulatory and other agencies regarding clinical medical-necessity determinations
Identify, plan, and coordinate medical-necessity reviews with relevant stakeholders
Maintain current knowledge of third-party payer and government requirements
Adapt communication and service explanations to patient populations while respecting privacy and obtaining permissions
Maintain licensure standards and pursue professional development
Ensure compliance with applicable federal, state, and local laws, accreditation standards, and regulatory requirements
Report known or suspected unethical conduct and patient, employee, privacy, or compliance concerns

Requirements

What you’ll need

Registered Nurse Diploma
Current Registered Nurse (RN) License in the state of practice
3 years of hospital-based experience delivering patient care as an RN
Experience in Case Management, Utilization Review and/or Discharge Planning in an Acute Care or Managed Care environment
Experience responding positively to change and working calmly and efficiently in high-pressure situations
Experience functioning independently and working well within a team setting
Computer skills and dexterity for patient-information data entry and retrieval
Proficiency with Windows-style applications, role-specific software packages, and keyboard
Effective verbal and written communication skills
Strong financial skills
Ability to work a flexible schedule, including 24/7, weekends, holidays, and on-call availability
Ability to travel throughout and between facilities
Ability to meet medium-work physical demands, stand for prolonged periods, and stoop, bend, reach, grab, and use manual dexterity
Ability to work in healthcare environments with potential exposure to blood, body fluids, tissue, communicable diseases, hazardous medications, and hazardous waste

Benefits

Comp & perks

Full-time employment
Professional/personal development opportunities
Reasonable accommodations for qualified individuals with disabilities
Equal opportunity employment