RN Case Manager - Day Shift, Care Coordination Leader

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

Job summary

MercyOne is seeking an RN Case Manager for an onsite, day-shift role in Des Moines, IA. You will review inpatient and outpatient records with attending physicians, coordinate authorizations with payers, and support appropriate admission status across the care continuum.

Responsibilities include utilization reviews, applying guidelines, documenting in STAR, and collaborating with case management and revenue teams to ensure accurate payer sourcing.

Qualifications

• Current Iowa RN license is required.
• 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.

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

Clinical nursing experience

Insurance knowledge

Utilization review

Communication skills

Independent decision-making

UR certification within 12 months (pre

Education

BSN preferred

Healthcare-related degree

Job description

MercyOne is seeking an RN Case Manager for an onsite, day-shift role in Des Moines, IA. You will review inpatient and outpatient records with attending physicians, coordinate authorizations with payers, and support appropriate admission status across the care continuum.

Responsibilities include utilization reviews, applying guidelines, documenting in STAR, and collaborating with case management and revenue teams to ensure accurate payer sourcing.