Onsite RN Case Manager – Utilization & Payer Advocate

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

Job summary

Trinity Health in Des Moines, IA is seeking a RN Case Manager to work onsite, reviewing inpatient and outpatient records to determine admission status in collaboration with physicians and the Case Management staff. You will interact with insurance providers to obtain authorizations and ensure continued stay approvals, documenting interactions in the STAR admitting system.

This role requires strong clinical judgment, effective communication, and the ability to navigate a fast-paced healthcare

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 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 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 licensure

5+ years nursing

Clinical judgment

Communication skills

Independent decision-making

Utilization review knowledge

UR certification within 12 months

Education

BSN or healthcare-related degree

Job description

Trinity Health in Des Moines, IA is seeking a RN Case Manager to work onsite, reviewing inpatient and outpatient records to determine admission status in collaboration with physicians and the Case Management staff. You will interact with insurance providers to obtain authorizations and ensure continued stay approvals, documenting interactions in the STAR admitting system.

This role requires strong clinical judgment, effective communication, and the ability to navigate a fast-paced healthcare