RN Case Manager - Night Shift: Utilization & Coordination

Trinity Health; Des Moines (IA); On-site; USD 68,000 - 82,000; Full time

Job summary

Mercy Medical Center is seeking an RN Case Manager for the on-site Nights shift. The role covers reviewing inpatient/outpatient admissions, authorizations, and payer communications, with three 12-hour night shifts per week and rotating weekend coverage.

Responsibilities include collaboration with physicians, documentation in STAR, education of patients and families, and maintaining timely status updates across departments. Iowa RN license and 5+ years’ nursing experience are required.

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

Clinical judgment

Communication

Independent decision-making

Collaboration

Utilization review knowledge

Education

Iowa RN license

BSN or healthcare-related degree preferred

Five years clinical nursing experience

Tools

STAR system

Utilization Review tools

Job description

Mercy Medical Center is seeking an RN Case Manager for the on-site Nights shift. The role covers reviewing inpatient/outpatient admissions, authorizations, and payer communications, with three 12-hour night shifts per week and rotating weekend coverage.

Responsibilities include collaboration with physicians, documentation in STAR, education of patients and families, and maintaining timely status updates across departments. Iowa RN license and 5+ years’ nursing experience are required.