RN Case Manager - Day Shift, Onsite Utilization Review

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

Job summary

Mercy Medical Center in Des Moines, IA seeks an experienced RN Case Manager for an onsite role. You will review inpatient and outpatient admission records and collaborate with physicians and payers to determine and secure appropriate admission status, ensuring accurate documentation in the STAR system.

Responsibilities include utilization reviews, applying care guidelines, and coordinating with verification and financial teams to facilitate payer approvals and continued stay.

Qualifications

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

Utilization Review

Insurance Liaison

Clinical Judgment

Communication

Education

Nursing License (RN)

BSN

Tools

STAR system

Job description

Mercy Medical Center in Des Moines, IA seeks an experienced RN Case Manager for an onsite role. You will review inpatient and outpatient admission records and collaborate with physicians and payers to determine and secure appropriate admission status, ensuring accurate documentation in the STAR system.

Responsibilities include utilization reviews, applying care guidelines, and coordinating with verification and financial teams to facilitate payer approvals and continued stay.