Night-Shift ED RN Case Manager: Utilization & Admissions

MercyOne Medical Group; Des Moines (IA); On-site; USD 65,000 - 90,000; Full time

Job summary

MercyOne Medical Group is seeking an experienced Registered Nurse for Utilization Review. This full-time night-shift role reviews inpatient and outpatient status, collaborates with physicians, and coordinates with Case Management, Verification, and Revenue Cycle to secure authorizations and ensure accurate payer sources.

Responsibilities include applying Milliman guidelines, documenting in the STAR system, and communicating status changes.

Qualifications

• Current Iowa RN license.
• Minimum of five years of clinical nursing experience.
• BSN or healthcare-related degree preferred.
• Knowledge of insurance eligibility, CMS rules, and utilization review processes.
• 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 months of hire.

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.

Skills

Utilization review

RN license

Communication

CMS rules

Education

RN license in Iowa

BSN preferred

Tools

STAR system

Milliman Care Guidelines

Job description

MercyOne Medical Group is seeking an experienced Registered Nurse for Utilization Review. This full-time night-shift role reviews inpatient and outpatient status, collaborates with physicians, and coordinates with Case Management, Verification, and Revenue Cycle to secure authorizations and ensure accurate payer sources.

Responsibilities include applying Milliman guidelines, documenting in the STAR system, and communicating status changes.