RN Case Manager (Night Shift) – Onsite & Utilization Review

Trinity Health; Iowa (LA); On-site; USD 90,000 - 115,000; Full time

Job summary

Mercy Medical Center is seeking an RN Case Manager for the onsite night shift (7:00 PM – 7:30 AM) at Mercy West Lakes. The role reviews admission records, collaborates with physicians, and obtains payer authorization for continued stay using STAR and Milliman guidelines.

Requirements include an Iowa RN license and 5+ years of nursing experience; BSN preferred. Strong clinical judgment and communication skills are essential in a fast-paced environment.

Qualifications

• Current Iowa RN license.
• Five (5) years of clinical nursing experience.
• BSN or healthcare-related degree preferred.
• Knowledge of insurance eligibility, CMS rules, and utilization review processes.
• 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.
• Apply Milliman Care Guidelines and payer criteria to determine patient status.
• Collaborate with attending physicians to clarify admission status and initiate reviews.
• Communicate status changes promptly to Case Management and Admitting.
• Provide patient/family education and issue Notices of Status Change when required.
• Document utilization review activities and authorizations in the medical record and STAR system.
• Submit clinical information to payers to support authorization and continued stay.
• Review and route denial notifications for appeal consideration; collaborate on appeals.
• Monitor insurance coverage and communicate updates to verification and financial teams.
• Participate in peer-to-peer reviews and advocate for appropriate admission status.

Skills

Clinical nursing experience

Communication

Independent decision making

Utilization review knowledge

Education

BSN or healthcare-related degree

Tools

STAR system

Milliman Care Guidelines

Job description

Mercy Medical Center is seeking an RN Case Manager for the onsite night shift (7:00 PM – 7:30 AM) at Mercy West Lakes. The role reviews admission records, collaborates with physicians, and obtains payer authorization for continued stay using STAR and Milliman guidelines.

Requirements include an Iowa RN license and 5+ years of nursing experience; BSN preferred. Strong clinical judgment and communication skills are essential in a fast-paced environment.