Case Manager-Utilization Review-RN

MercyOne Medical Group; Mason City (IA); On-site; USD 70,000 - 90,000; Full time

Job summary

MercyOne North Iowa Medical Center in Mason City, IA is seeking a full-time Utilization Review Case Manager RN for day shift. You will screen cases, secure insurance approval, and ensure timely services, with discharge planning and transition to appropriate services.

You will help ensure CMS compliance and payer guidelines, applying care plans and managed care concepts while coordinating with clinical teams and leveraging community resources.

Qualifications

• Licensed RN in Iowa is required.
• Five years of RN experience with community contact and management of care.
• BSN preferred; utilization management certifications preferred.

Responsibilities

• Case screening and insurance approval, ensuring timely services.
• Facilitate discharge with transition to appropriate services.
• Ensure CMS rules and payer guidelines compliance to avoid denials.
• Achieve patient outcomes via care plans, managed care concepts, and resource management.
• Collaborate with clinical disciplines and utilize community resources.

Skills

RN license

Case management

Data systems

CQI

Communication

Education

RN license in Iowa

BSN preferred

Utilization management certifications preferred

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

Special Skills and Competencies

• 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.