ED RN Case Manager Nights

MercyOne; Des Moines (IA); On-site; USD 70,000 - 90,000; Full time

Job summary

Mercy Medical Center in Des Moines, IA seeks an experienced RN Case Manager for full-time night shifts to review admissions, coordinate utilization management, and secure payer authorizations. The role collaborates with physicians, case management, and revenue cycle teams to ensure accurate status and documentation in STAR system.

Onsite office-based position with rotating weekends. Requirements include Iowa RN license, 5+ years clinical nursing, knowledge of CMS rules and utilization review;

Qualifications

• Current Iowa RN license.
• Minimum of five (5) years of clinical nursing experience.
• Knowledge of insurance eligibility, CMS rules, and utilization review processes.
• Utilization Review certification within 12 months of hire preferred.
• Completion of Mandatory Reporter abuse training within three (3) months of hire.

Responsibilities

• Perform admission, concurrent, and post-discharge utilization reviews per the Utilization Management Plan and regulatory requirements.
• Apply Milliman Care Guidelines and payer-specific criteria to determine appropriate patient status.
• Collaborate with attending physicians to clarify admission status and initiate second-level reviews as needed.
• Communicate status changes promptly to Case Management, Admitting, and other departments.
• Provide patient/family education and issue Notices of Status Change when required.
• Document utilization review activities and authorizations in the medical record and STAR system.
• Submit clinical information to payers to prevent denials and support authorization and continued stay.
• Route denial notifications for appeal and collaborate with post-denials teams.
• Monitor insurance coverage and update verification and financial teams.
• Participate in peer-to-peer reviews to advocate for appropriate admission status.

Education

Current Iowa RN license

BSN or healthcare-related degree preferred

Job description

Employment Type:Full time Shift:12 Hour Night Shift Description:RN Case Manager (Onsite) Nights

Full-time night shift (7:00 PM - 7:30 AM), working three 12-hour shifts per week with rotating weekend coverage.

General Summary

Responsible for the review of inpatient and outpatient admission records for appropriate admission status at Mercy Medical Center and Mercy West Lakes. Works in collaboration with the attending physician and the Case Management staff utilizing admission criteria guidelines-and second level physician review process when appropriate. Interacts with insurance providers to obtain authorization and continued stay approval for admission. Collaborates with the Verification department, Revenue cycle and Medical Eligibility to facilitate the establishment of the correct payer source for patient stay and the documentation of the interactions in the STAR admitting system

Key Responsibilities

• Perform admission, concurrent, and post-discharge utilization reviews in accordance with the Utilization Management Plan and regulatory requirements.
• Apply Milliman Care Guidelines and payer-specific criteria to determine appropriate patient status.
• Collaborate with attending physicians to clarify admission status and initiate second-level physician reviews as needed.
• Communicate status changes promptly to Case Management, Admitting, and other relevant departments.
• Provide patient/family education and issue Notices of Status Change when required.
• Accurately document utilization review activities, status determinations, authorizations, denials, and communications in the medical record and STAR system.
• Submit timely clinical information to payers to prevent technical denials and support authorization and continued stay.
• Review and route denial notifications for appeal consideration; collaborate with post-denials, RAC, and appeal teams.
• Monitor insurance coverage and communicate updates to verification and financial teams.
• Participate in peer-to-peer reviews and advocate for appropriate admission status and continued stay.

Qualifications

• Current Iowa RN license.
• Minimum of five (5) years of clinical nursing experience.
• BSN or healthcare-related degree preferred.
• Knowledge of insurance eligibility, CMS rules, and utilization review processes across the continuum of care.
• Strong clinical judgment, communication, and independent decision-making skills.
• Utilization Review certification within 12 months of hire preferred.
• Completion of Mandatory Reporter abuse training within three (3) months of hire.

Work Environment & Physical Requirements

• Primarily office-based with computer, phone, and documentation tasks.
• Light physical activity with occasional lifting; use of assistive devices and additional personnel as required.
• Visual acuity sufficient to review medical records and electronic systems.
• Ability to work collaboratively in a fast-paced, high-stress healthcare environment while maintaining professionalism and courtesy.

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.