RN Case Manager: Onsite Utilization & Care Coordination

IHA; Des Moines (IA); On-site; USD 70,000 - 90,000; Full time

Job summary

Mercy Medical Center in Des Moines, IA is seeking an RN Case Manager (Onsite) to review inpatient and outpatient admissions, coordinate with physicians, and secure authorizations for continued stay. The role collaborates with verification, Revenue cycle, and eligibility teams to ensure accurate payer sources and proper documentation in STAR.

The incumbent will perform utilization reviews, apply CMS and Milliman guidelines, and communicate status changes to care teams.

Qualifications

• Current Iowa RN license.
• Minimum of five (5) years of clinical nursing experience.
• 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 Iowa

5+ years nursing experience

Clinical judgment

Education

BSN or healthcare-related degree preferred

Job description

Mercy Medical Center in Des Moines, IA is seeking an RN Case Manager (Onsite) to review inpatient and outpatient admissions, coordinate with physicians, and secure authorizations for continued stay. The role collaborates with verification, Revenue cycle, and eligibility teams to ensure accurate payer sources and proper documentation in STAR.

The incumbent will perform utilization reviews, apply CMS and Milliman guidelines, and communicate status changes to care teams.