RN Utilization Review: Clinical Care & Payer Coordination

LCMC Health; New Orleans (LA); On-site; USD 75,000 - 115,000; Full time

Benefits offered by this job

Deliver healthcare with heart

Give people a reason to smile

Put a little love in your work

Be honest and real, but with compasson

Bring lagniappe into everything you do

One-of-a-kind care

See opportunities, not problems

Cheerlead ideas and differences

Love what makes you, you

Job summary

LCMC Health, a Louisiana-based health system in New Orleans, seeks an experienced RN to support Emergency Department and utilization functions. The position involves 12-hour shifts and is based in New Orleans, LA.

Responsibilities include care reviews, medical necessity determinations, CMS/payer status assignments, and advocacy to prevent denials, with emphasis on regulatory compliance and cross-functional collaboration with physicians and leaders.

Qualifications

• Current RN nursing license to practice in Louisiana (as defined by the Louisiana State Board of Nursing).
• 2 years of professional nursing in Emergency Department or Utilization experience highly preferred.

Responsibilities

• Perform appropriate level of care reviews.
• Identify gaps or barriers in treatment plans.
• Make medical necessity determinations.
• Accurately assign patient status in accordance with CMS and payer guidelines.
• Coordinate efforts for prevention of payer denials.
• Performs timely status conversions when appropriate.
• Maintain Regulatory Compliance.
• Peer-to-peer (P2P) review processing.
• Interact with LCMC Health care partners, leadership and/or physicians to discuss clinical questions, concerns, strategies, and care plans to achieve quality and cost management objectives.
• Document all workflows in EPIC system for purposes of tracking and quality assessment.

Skills

RN License

ED Experience

Job description

LCMC Health, a Louisiana-based health system in New Orleans, seeks an experienced RN to support Emergency Department and utilization functions. The position involves 12-hour shifts and is based in New Orleans, LA.

Responsibilities include care reviews, medical necessity determinations, CMS/payer status assignments, and advocacy to prevent denials, with emphasis on regulatory compliance and cross-functional collaboration with physicians and leaders.