Case Manager-Utilization Review-RN

Trinity Health; Mason City (IA); On-site; USD 85,000 - 110,000; Full time

Job summary

MercyOne North Iowa Medical Center seeks a qualified Utilization Review Case Manager (RN) to screen cases, obtain insurance approvals, and ensure timely services with discharge planning to appropriate settings. You will help ensure CMS compliance and adherence to payer guidelines to prevent denials and revenue loss.

Ideal candidates hold Iowa RN licensure with a Bachelor's degree (BSN preferred) and five years of RN experience in managed care or community settings.

Qualifications

• Licensed RN in Iowa required.
• Bachelor's degree required.
• BSN preferred.
• Utilization management certifications recognized in Iowa preferred.
• Five years RN experience involving community contact, managed care, resource utilization and Medicaid/insurance.
• Case management experience preferred.
• Knowledge of data systems and CQI; familiarity with community resources.

Responsibilities

• Screen cases for utilization review and obtain insurance approvals.
• Ensure timely services and discharge planning with transition to appropriate services.
• Help ensure CMS compliance and payer guidelines to prevent denials and revenue loss.
• Collaborate with clinical disciplines to apply care plans and manage resources.

Skills

Case management

Managed care

Data analysis

Communication

Independent work

Judgment & decision-making

Collaboration

Education

Bachelor's Degree

BSN preferred

Tools

EMR systems

Care coordination software

Job description

Employment Type: Full time Shift: Day Shift Description: Hours: Monday-Friday: Days; no holidays

About The Job

The Utilization Review Case Manager responsibilities include case screening, insurance approval, assurance of timely services, and facilitation of discharge with transition to the appropriate services. Assists the organization in ensuring compliance with CMS rules and regulations and conditions of participation as well as commercial payer specific guidelines to prevent denials and revenue loss. Patient outcomes are achieved through effective application of care plans, managed care concepts, appropriateness criteria, resource management, knowledge of community resources, and collaboration with other clinical disciplines.

What We Are Looking For

• Education [formal]: Licensed registered nurse in the state of Iowa.
• Bachelor's Degree required.
• BSN preferred.
• Utilization management focused certifications that are recognized in the state of Iowa preferred
• Experience: Five years of experience as a registered nurse involving community contact, knowledge of managed care, resource utilization criteria, Medicaid, insurance coverage for acute care and skilled care
• Case management experience preferred.
• Knowledge/skills with data systems, continuous quality improvement (CQI), community healthcare resources.
• Ability to work independently in analyzing data, exercising judgment to arrive at conclusions.
• Ability to establish and maintain working relationships.
• Assertiveness and critical thinking.
• Ability to communicate effectively and tactfully both verbally and in writing.
• Skill in exercising a high degree of initiative, judgment, discretion, and decision-making.
• Ability to plan, prioritize, organize and direct the work of others.
• Ability to communicate clearly and effectively.
• Willingness to accept responsibility and to be accountable for own actions.
• Must be able to read, write, and/or speak English.
• Must provide proof of Basic Life Support (BLS Provider-American Heart Association or Professional Rescuer-American Red Cross) prior to employment or within 30 days of hire and maintains current status.
• Must provide proof of Mandatory Reporting for Child and Dependent Adult Abuse training prior to employment or within 6 months of hire and maintain current status.
• All offers are contingent upon the successful completion of references, background checks, pre-employment physical, drug screen and post offer exam.
• EEO Employer F/M/Veteran/Disabled In compliance with the ADA Amendments Act (ADAAA), VEVRAA, and Section 503, should you have a disability and would like to request an accommodation in order to apply for a currently open position with MercyOne North Iowa Medical Center, please call Human Resources at [phone] or email us at [e-mail]

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are 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, disability, veteran status, or any other status protected by federal, state, or local law.

Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.