Night Shift RN Case Manager - Utilization & Admissions

MercyOne; Des Moines (IA); On-site; USD 75,000 - 95,000; Full time

Job summary

MercyOne is seeking an RN Case Manager for the on-site Night shift. The role involves reviewing inpatient/outpatient admissions, coordinating with physicians and payers, and ensuring appropriate authorization for continued stay.

You will collaborate with case management, verification, and revenue cycles in a fast-paced hospital setting. The ideal candidate holds an Iowa RN license with 5+ years of nursing experience, a BSN or healthcare-related degree preferred, and familiarity with CMS rules

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.
• 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 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

RN license

Utilization review

Case management

CMS rules

Payer communication

Independent decision-making

Education

BSN preferred

Healthcare-related degree

Job description

MercyOne is seeking an RN Case Manager for the on-site Night shift. The role involves reviewing inpatient/outpatient admissions, coordinating with physicians and payers, and ensuring appropriate authorization for continued stay.

You will collaborate with case management, verification, and revenue cycles in a fast-paced hospital setting. The ideal candidate holds an Iowa RN license with 5+ years of nursing experience, a BSN or healthcare-related degree preferred, and familiarity with CMS rules