RN Case Manager: Weekend Utilization & Payer Expert

Trinity Health; Des Moines (IA); On-site; USD 75,000 - 99,000; Full time

Job summary

Mercy Medical Center in Des Moines, IA, seeks an RN Case Manager to assess inpatient and outpatient admission status onsite. You will collaborate with physicians and Case Management to obtain authorizations and manage continued stay using STAR system.

Responsibilities include utilization reviews, communication with payers, and coordinating with Verification, Revenue cycle, and Medical Eligibility to ensure accurate payer source and documentation.

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

5+ yrs nursing

BSN preferred

Case management

Utilization review

Communication

Independent decision-making

Education

BSN or healthcare-related degree

Utilization Review certification within 12 months

Mandatory Reporter abuse training within 3 months

Job description

Mercy Medical Center in Des Moines, IA, seeks an RN Case Manager to assess inpatient and outpatient admission status onsite. You will collaborate with physicians and Case Management to obtain authorizations and manage continued stay using STAR system.

Responsibilities include utilization reviews, communication with payers, and coordinating with Verification, Revenue cycle, and Medical Eligibility to ensure accurate payer source and documentation.