Onsite RN Case Manager: Admissions & Utilization Expert

MercyOne Medical Group; Des Moines (IA); On-site; USD 65,000 - 85,000; Full time

Job summary

MercyOne Medical Group is seeking an RN Case Manager to review inpatient and outpatient admission records for appropriate status at Mercy Medical Center and Mercy West Lakes. You will collaborate with physicians and Case Management, obtain authorizations, and document interactions in the STAR admitting system.

The role involves utilization reviews, communicating status changes, and supporting continued stay while interfacing with verification and revenue cycle teams.

Qualifications

• Current Iowa RN license.
• Knowledge of insurance eligibility, CMS rules, and utilization review processes.
• Strong clinical judgment 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

Clinical nursing

Communication

Decision making

Education

BSN or healthcare-related degree

Job description

MercyOne Medical Group is seeking an RN Case Manager to review inpatient and outpatient admission records for appropriate status at Mercy Medical Center and Mercy West Lakes. You will collaborate with physicians and Case Management, obtain authorizations, and document interactions in the STAR admitting system.

The role involves utilization reviews, communicating status changes, and supporting continued stay while interfacing with verification and revenue cycle teams.