RN Case Manager - Weekend Utilization & Admissions

Trinity Health; Central City (IA); On-site; USD 70,000 - 90,000; Full time

Job summary

Mercy Medical Center in Iowa is seeking an RN Case Manager for onsite weekend shifts. The role reviews inpatient and outpatient admissions, collaborates with physicians, and works with payers to obtain authorization and continued stay approvals using STAR and related processes.

Qualified candidates have an Iowa RN license, 5+ years clinical nursing experience, and knowledge of utilization review and CMS rules. BSN preferred; VR/abuse training completed within 3 months is expected.

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 license IA

Case management

Utilization review

Communication skills

Independent decision-making

Education

BSN preferred

Tools

STAR system

Job description

Mercy Medical Center in Iowa is seeking an RN Case Manager for onsite weekend shifts. The role reviews inpatient and outpatient admissions, collaborates with physicians, and works with payers to obtain authorization and continued stay approvals using STAR and related processes.

Qualified candidates have an Iowa RN license, 5+ years clinical nursing experience, and knowledge of utilization review and CMS rules. BSN preferred; VR/abuse training completed within 3 months is expected.