Weekend RN Case Manager: Utilization & Care Coordination

Trinity Health Mid-Atlantic; Des Moines (IA); On-site; USD 75,000 - 105,000; Full time

Job summary

Trinity Health seeks an experienced RN Case Manager for on-site weekend coverage at Mercy Medical Center and Mercy West Lakes. You will review inpatient and outpatient admissions, collaborate with physicians, and obtain payer authorizations to ensure appropriate admission status and continued stay.

Role requires strong clinical judgment, knowledge of CMS rules and utilization review processes, and excellent communication with insurance providers and hospital staff. Equal opportunity employer.

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 per the Utilization Management Plan and regulations.
• Apply Milliman Care Guidelines and payer-specific 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 departments.
• Educate patients/families and issue Notices of Status Change when required.
• Document utilization review activities, determinations, authorizations, denials, and communications in the medical record and STAR system.
• Submit clinical information to payers to prevent denials and support authorization/continued stay.
• Review and route denial notifications for appeal; collaborate with post-denials, RAC, and appeals teams.
• Monitor insurance coverage and inform verification and financial teams of updates.
• Participate in peer-to-peer reviews and advocate for appropriate admission status and continued stay.

Skills

Clinical nursing experience

Communication skills

Independent decision-making

Utilization review

Education

BSN or healthcare-related degree

Current Iowa RN license

Job description

Trinity Health seeks an experienced RN Case Manager for on-site weekend coverage at Mercy Medical Center and Mercy West Lakes. You will review inpatient and outpatient admissions, collaborate with physicians, and obtain payer authorizations to ensure appropriate admission status and continued stay.

Role requires strong clinical judgment, knowledge of CMS rules and utilization review processes, and excellent communication with insurance providers and hospital staff. Equal opportunity employer.