A. Experience, Knowledge and Skill: 1. Previous Experience: A Minimum three years of clinical nursing, case management and/or utilization review experience. Emergency services and/or utilization review/case management experience preferred.
2. Specialized or Technical Education a. Registered Nurse licensed to practice in the State of Louisiana. b. Knowledge of established medical necessity criteria and their application necessary. c. Knowledge of Medicare, Medicaid, HMO/Commercial Insurance, MS-DRG's, other payment methodologies, Social Services, discharge planning, community resources, and referral agencies strongly preferred. d. Knowledge of ICD-9-CM coding, Case Mix Index monitoring, and legal compliance, and clinical documentation preferred. e. Knowledge of Peer Review and payor functions necessary. f. Knowledge of third party payor appeal process necessary. g. Knowledge of Quality Improvement activities/Team Leader/Facilitator training preferred.
3. Manual or Physical Skills
Basic Computer skills preferred.
4. Physical Effort Required
Strength: Sedentary Push: occasionally Pull: occasionally Carry: occasionally Lift: occasionally Sit: frequently Stand: frequently Walk: frequently