Utilization Review RN – Day Shift (On-Site)

Trinity Health Corp.; Des Moines (IA); On-site; USD 75,000 - 95,000; Full time

Job summary

MercyOne Des Moines Medical Center, part of Trinity Health, is seeking a Utilization Management Review nurse for a full-time day shift on-site in Des Moines, IA. You will review inpatient/outpatient admissions, collaborate with physicians and case management, and ensure proper payer authorization and documentation.

Requirements include Iowa RN licensure, 5 years nursing experience, and knowledge of insurance eligibility rules. MRT/Utilization Review certification within 12 months is preferred.

Qualifications

• Current licensure as a registered nurse in the State of Iowa.
• Five (5) years clinical nursing experience.
• Bachelor of Science - Nursing or degree in healthcare-related field preferred.
• Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire.
• Knowledge of eligibility requirements for insurance coverage with respect to health care services: ambulatory, observation stays, surgical, acute care, subacute and continuum of care services.
• Demonstrated ability to manage complex management and clinical situations.
• Ability to work within a function independently exercising judgement to reach resolutions to issues.
• Specialty certification in Utilization Review within 12 months of hire preferred.

Responsibilities

• Conducts admission review per the Utilization Management Plan to ensure hospitalization is approved.
• Applies Milliman Careguidelines Criteria for appropriate status determination.
• Engages with attending physician for status clarification or correction.
• Engages second level physician review as indicated.
• Ensures timely communication with Case Management for status changes.
• Provides education/information to patient/family about status changes.
• Documents in Medical Record Utilization Management forms reflecting criteria and status.
• Collaborates with MercyOne Post Denials team for potential appeals.
• Notifies Admitting of status changes or discrepancies.
• Reviews admission records for CMS rules on status.

Education

Bachelor of Science - Nursing or degree in healthcare-related field

Job description

MercyOne Des Moines Medical Center, part of Trinity Health, is seeking a Utilization Management Review nurse for a full-time day shift on-site in Des Moines, IA. You will review inpatient/outpatient admissions, collaborate with physicians and case management, and ensure proper payer authorization and documentation.

Requirements include Iowa RN licensure, 5 years nursing experience, and knowledge of insurance eligibility rules. MRT/Utilization Review certification within 12 months is preferred.