PCS Case Manager/Utilization Review Nurse

The PCS Case Manager/Utilization Review Nurse (UR) is responsible for monitoring and justifying the acute level of care according to criteria established by State and Federal regulatory agencies, insurance companies, and other third-party payers. Through ongoing open chart review, the PCS Case Manager/Utilization Review Nurse helps facilitate the documentation process with physicians and hospital staff in substantiating the patient’s assigned level of care and coordinating discharge planning based on the individual needs of the patient. The PCS Case Manager/Utilization Review Nurse acts as a liaison and facilitator for the patient, his/her family, physicians, hospital administration, and staff personnel regarding problem-solving in discharge planning and management of complex medical and psychosocial issues. The PCS Case Manager/Utilization Review Nurse supports the philosophy, purpose, and objectives of the hospital and nursing department as well as promotes stewardship of resources by fostering awareness of reimbursement concerns to the patient, his/her family, physicians, and hospital personnel as mentioned above. The PCS Case Manager/Utilization Review Nurse acts on behalf of the PCS Coordinator in his/her absence and may assume weekend call responsibilities on a rotating basis. The PCS Case Manager/Utilization Review Nurse has well-developed knowledge and skills in the areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. This individual monitors the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed. This person actively participates in process improvement initiatives, working with various departments and multi-disciplinary staff. This role is responsible for ensuring that the UM program maintains documented, up-to-date policies and procedures and ensures that all UM key processes have valid outcome measures that are monitored for compliance and reported to a variety of audiences. The UR Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment.

Eligible for medical coverage on your first day of employment, all other benefits will be effective the 1st of the month following hire date! 

Requirements:

40 hours per week - First Shift

8:00 am - 4:30 pm

Monday - Friday

Valid RN License in the State of Indiana

BLS/CPR certification

Assoc. degree or bachelor's degree in social, nursing or health related field. 

3-5 years hospital experience preferred. 

Basic knowledge of computers and keyboarding. 

Workable knowledge of medical terminology, including Medicare guidelines for admissions and discharges.