RN Case Manager: Inpatient Utilization & Authorization

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

Job summary

Trinity Health in Des Moines, IA, seeks an experienced RN Case Manager to review inpatient and outpatient records, determine admission status, and coordinate authorizations with payers. This onsite role collaborates with physicians, the Case Management team, and other departments to ensure accurate payer sources and compliant documentation.

The position emphasizes utilization review, payer communications, and timely status changes, with a Monday–Friday schedule, no weekends, and a focus on

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.
• 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 licensure

5+ years experience

BSN preferred

Utilization review

Interdisciplinary collaboration

Independent decision-making

Education

BSN preferred

Job description

Trinity Health in Des Moines, IA, seeks an experienced RN Case Manager to review inpatient and outpatient records, determine admission status, and coordinate authorizations with payers. This onsite role collaborates with physicians, the Case Management team, and other departments to ensure accurate payer sources and compliant documentation.

The position emphasizes utilization review, payer communications, and timely status changes, with a Monday–Friday schedule, no weekends, and a focus on