Nurse Case Manager/Utilization Review - FT Exempt $73,923.20-$108,763.20 Annually

Spanish Peaks Regional Health Center (SPRHC) is currently seeking a compassionate and detail-driven Nurse Case Manager to support our Medical/Surgical and Extended Care Services. This vital role combines clinical expertise with case management and discharge planning to ensure patients receive safe, efficient, and appropriate care—while maintaining compliance with CMS and payer requirements. 

Pay Range: $73,923.20-$108,763.20 Annually (Exempt) depending on experience and qualifications. 

Summary:  The Nurse Case Manager is responsible for reviewing patient records and care plans to determine the medical necessity of admission, treatment, and length of stay. This role supports compliance with Medicare and insurance reimbursement standards while actively contributing to quality improvement and patient advocacy within the Critical Access Hospital framework. 

Essential Job Functions:

• Function as an expert practitioner who provides for the clinical needs in the Medical Surgery and Extended Care Units, both directly and indirectly.

• Utilizing Centers for Medicaid and Medicare Regulations and Guidelines (CMS), establishes and maintains an active quality improvement plan and participants in infection control programs including attending regularly scheduled meetings.

• Within assigned work team, assumes responsibility for proactively identifying and resolving customer problems and requests for assistance in the completion of discharge planning and utilization review.

• Supports team objectives focusing on team results, handling conflict in a positive manner, sharing information and resources and listening effectively to team members while assuming responsibility for personal contributions.

• Work one-on-one with nursing staff as needed to enhance the delivery of patient care regarding utilization review and discharge planning.

• Analyzes insurance, governmental and accrediting agency standards to determine criteria concerning admissions, treatment and length of stay of patients in the Medical/Surgery and Extended Care Services.

• Uses all relevant guidance criteria for appropriateness for patient status and follow utilization review plan.

• Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.

• Gathers data from records and maintains relevant statistics.

• Determines patient review dates according to established diagnostic criteria.

• Assists review committee in planning and holding federally mandated quality assurance reviews.

• Perform discharge planning evaluations and as indicated, implement discharge planning for at-risk patients.

• Oversee the utilization of resources to promote judicious use of services and enhance fiscal responsibility within the boundaries of liability concerns.

• Perform as a navigator for the patient in coordinating hospital resources, community resources and any other applicable resources for the patient care after discharge.

• Perform Care Plan meetings with patients, family members and members of the interdisciplinary team for all extended care services.

• Prepares required reporting information and submits data required for extended care services and swing bed services. 

• Perform other functions as required to fulfill the expectations of the Nurse Case Manager role.

Minimum Required Education/Experience: Associate’s Degree in Nursing is required. Minimum of one year work experience in hospital nursing care is required. Previous work experience in Critical Access Hospital nursing background is preferred.  

Pre-Employment Knowledge, Abilities and Skills: 

• Knowledge of CMS regulations in relation to Critical Access Hospital participation.

• Ability to operate general office equipment including computer software applications (e-mail, surveillance equipment/cameras).

• Outstanding verbal and written communication skills.

• Knowledge of the principles and practices of discharge planning in a healthcare facility.

• Ability to establish and maintain effective relationships with the public, other agencies, employees and administration.

• Ability to maintain and oversee multiple clinical interactions ensuring timeliness in response to needs of employees and patients.

Note: An acceptable combination of education, training and experience that provides the above knowledge, abilities and skills may be substituted.

Necessary Special Requirements: Must obtain annual flu vaccination and any job-specific immunizations. Required to submit to a tuberculosis screening process.

Licenses or Certificates: Valid state license as an LPN or RN. Current Basic Life Support/CPR certification.