Director - Ohp Utilization Management/Care Management

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 upholds the strategic vision, direction and overall accountability for the Utilization Management Department.
Develops, implements and monitors strategies for cost reduction and utilization management.
Implements and leads all regulations related to utilization management and revenue cycle operations.
Provides oversight/administration of the standard operating policies and procedures required for the success in the division.
Independently makes daily operational management, decisions that could seriously affect the overall Revenue Cycle division and/or company's financial objectives, performance objectives and strategic results.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.


This job description is a summary of the primary duties and responsibilities of the job and position.
It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities.
Contents are subject to change at the company's discretion.


Education

Required - Bachelor's degree in nursing.


Preferred - Master's degree in nursing.


Work Experience

Required - 7 years of case management experience in a managed care or acute care setting, including 3 years of leadership experience.


Certifications

Required - Registered Nurse (RN) license in the state of practice.


Preferred - Certified Case Manager (CCM), Accredited Case Manager (ACM), or Certified Professional in Healthcare Management (CPHM).


Knowledge Skills and Abilities (KSAs) Proficiency in using computers, software, and web-based applications.
Effective verbal and written communication skills and ability to present information clearly and professionally.
Strong interpersonal skills.
Excellent communication skills and ability to work collaboratively with Executives, leadership, and support staff.
Ability to anticipate issues that adversely impact the function of the department and use deductive reasoning skills to solve problems.
Excellent judgment, organization skills, group facilitation skills, decision making and delegating skills.
Ability to demonstrate a positive, professional attitude, foster teamwork and exhibit excellent self-direction, good judgement in handling difficult situations and good organizational, time management, interpersonal and conflict resolution skills.
Job Duties Lead and directs Utilization Review (UR) staff and functions, including staffing, staff engagement, training, purchasing, departmental budgeting, and labor management.
Assists in developing policies, standard operating procedures and programs that incorporate best practices and ensure effective, compliant utilization reviews.
Implements and leads regulations for utilization management, including admission and continued stay medical necessity criteria review, payer authorization, denials management, and ensures adherence to the established utilization management plan.
Manages and monitors performance to ensure reviews are completed accurately and are appropriately reviewed with Providers in a timely manner.
Manages the completion of retro-active audit reviews to identify escalation issues regarding Providers, other facility issues, individual utilization review staff skills, payor-based concerns and to provide teaching material for UR staff.
Analyzes and reports utilization trends, patterns and impacts to the organization and make suggestions for improvement.
Appropriately escalates payor-based issues on both individual cases and identifies practice pattern issues to ensure appropriate coverage of patient's stay.
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.
Performs other related duties as assigned.


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.


This employer maintains and complies with its 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.
The employer is an Equal Opportunity Employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.


Physical and Environmental Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects.
Physical demand requirements are in excess of those for Sedentary Work.
Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.
NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.


Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid.


The incumbent has no occupational risk for exposure to communicable diseases.


Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste.
The risk level of exposure may increase depending on the essential job duties of the role.


Are you ready to make a difference?
Apply Today! Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website.

Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Maryland, New York, Washington, and Washington D.C.

Ochsner Health endeavors to make our site accessible to all users.
If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or ******.
This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.

We are proud to be an Equal Employment Opportunity and Affirmative Action employer.
We are committed to the principles of equal employment opportunity and providing a workplace that is free from discrimination based on race, color, creed, religion, pregnancy status, pregnancy-related conditions, national origin, ancestry, mental or physical disability, medical condition, age, veteran status, military status, citizenship status, marital status, familial status, sexual orientation, gender, gender identity or expression, genetic information, political affiliation, unemployment status, or any other characteristic protected under applicable federal, state or local law.
These protections extend to applicants and all employment related decisions.
View the EEO is the Law poster and its supplement, as well as the pay transparency policy for more information.


Affirmative Action Policy Statement