Weekend RN Case Manager: Utilization & Discharge Expert

MercyOne Medical Group; Des Moines (IA); On-site; USD 44,000 - 58,000; Part time

Job summary

MercyOne Medical Group in Des Moines, IA is seeking an RN Case Manager to review inpatient and outpatient admission records, collaborate with physicians, and secure ongoing authorizations. This onsite role focuses on accurate payer source documentation and utilization management within STAR systems.

The position requires strong clinical judgment, insurance knowledge, and the ability to coordinate with multi-disciplinary teams to ensure appropriate admission status and timely patient care

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

Clinical judgment

Communication

Independent decision-making

Education

RN license (Iowa)

BSN or healthcare-related degree

Job description

MercyOne Medical Group in Des Moines, IA is seeking an RN Case Manager to review inpatient and outpatient admission records, collaborate with physicians, and secure ongoing authorizations. This onsite role focuses on accurate payer source documentation and utilization management within STAR systems.

The position requires strong clinical judgment, insurance knowledge, and the ability to coordinate with multi-disciplinary teams to ensure appropriate admission status and timely patient care