RN Case Management/Utilization Review

*Please note: We are hiring for four (4) roles:

• Three (3) full‑time hybrid positions
• One (1) hybrid role with weekend‑only hours

Our Mission:

Our mission is to drive financial wellness in healthcare organizations so more patients can receive the care they need.

Our Vision:

Our vision is a future where we help healthcare organizations thrive in a complex ecosystem by clearing a path to financial health.

Our Culture:

We are committed to creating a workplace where every member feels valued, empowered, and inspired to contribute their best. Together we will foster a culture that promotes work-life balance and celebrates community engagement, personal achievements, milestones, and special occasions.

Values:

Integrity – We do what's right, no matter what.

Innovation – We use a harmonious blend of data, tech, and a human-centric approach.

Compassion – We understand the stress of healthcare organizations and their patients.

Determination –Our mission is our guiding force.

Partnership –We build enduring relationships through listening, communication and accountability.

Dignity: We have significant pride in each other and our work.

Job Summary: The Case Management/Utilization Review Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of inpatient and observation services for PC3 clients within the hospital setting. This role ensures accurate level-of-care determinations while maintaining compliance with CMS, state, and commercial payor regulations. The nurse communicates effectively with providers, case managers, physician advisors, and payors to support timely reviews and decisions.

In addition, the RN CM/UR works collaboratively with Physician Advisors to support case reviews, leveraging strong clinical expertise, payor criteria knowledge, and experience in acute care coordination workflows. This role also provides guidance and support to clients to promote best practices and achieve high-quality outcomes related to care coordination and utilization review.

By promoting optimal patient flow, reducing avoidable denials, and ensuring high-quality, cost-effective care, the Case Management/Utilization Review Nurse plays a critical role in improving both clinical and financial outcomes for PC3 clients.

This position reports directly to the Chief CM Officer

Supervisory Responsibilities:

This position does not have direct supervisory responsibilities.

Duties/Responsibilities:

• Perform concurrent and retrospective reviews to validate medical necessity using evidence-based criteria (e.g., MCG, InterQual, CMS guidelines).
• Determine and document appropriate patient status (inpatient vs. observation).
• Review admission orders, diagnostic results, progress notes, and treatment plans for appropriate placement and continuation of stay.
• Follows inpatients without authorization and communicates accordingly to PC3 PA team and PC3 clients.
• Communicate clinical information to payors for authorization, continued stay reviews, and clarification requests.
• Collaborate with physicians, advanced practice providers, nursing, case management, PC3 Physician Advisors, and other PC3 staff to resolve barriers to timely discharge or status decisions.
• Provide real-time feedback to providers regarding documentation needs and medical necessity requirements.
• Prepare and submit clinical information to support authorization and prevent avoidable denials when applicable.
• Assist in appeals, submission of cases and escalation processes as needed.
• Ensure thorough and accurate documentation of UR activities in the APEX, EMR and utilization management systems.
• Maintain up-to-date knowledge of CMS Conditions of Participation, Two-Midnight Rule, state Medicaid rules, and commercial payor policies.
• Ensure processes meet federal, state, and accreditation requirements (e.g., The Joint Commission, URAC).
• Protect patient confidentiality and comply with HIPAA and hospital privacy policies.
• Participate in audits, data collection, utilization reporting, and process improvement initiatives.
• Identify trends related to denials, delays, and variances in care delivery.
• Other duties as assigned.

Required Skills/Abilities:

• Knowledge related to electronic medical records
• Knowledge related to CMS Compliance
• Proficient in Microsoft Office applications.
• Strong interpersonal and organizational skills.

Education and Experience:

• RN with current licensure
• 3-5 years' experience in acute care Case Management/Utilization Review
• Strong understanding of utilization review, communication

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift up to 15 pounds at times.

Job Type: Full-time

Pay: Up to $100,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: Hybrid remote in Louisville, KY 40299