RN Case Manager - Weekend Admissions & Utilization Review

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

Job summary

Mercy Medical Center in Des Moines, IA is seeking an RN Case Manager to review inpatient and outpatient admissions, collaborate with physicians and Case Management, and facilitate authorization with payers. This onsite role involves cross-department coordination to ensure accurate payer source and proper admission status.

The position emphasizes utilization review, evidence-based criteria, and timely communication with departments to support patient care and continued stay approvals.

Qualifications

• Current Iowa RN license.
• At least 5 years of clinical nursing experience.
• Knowledge of insurance eligibility, CMS rules, and utilization review processes.
• Utilization Review certification within 12 months of hire preferred.
• Mandatory Reporter abuse training within 3 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 second-level 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

Education

BSN or healthcare-related degree

Job description

Mercy Medical Center in Des Moines, IA is seeking an RN Case Manager to review inpatient and outpatient admissions, collaborate with physicians and Case Management, and facilitate authorization with payers. This onsite role involves cross-department coordination to ensure accurate payer source and proper admission status.

The position emphasizes utilization review, evidence-based criteria, and timely communication with departments to support patient care and continued stay approvals.