Weekend RN Case Manager — Utilization & Payer Authorizations

Trinity Health; Central City (KY); On-site; USD 70,000 - 98,000; Full time

Job summary

Mercy Medical Center is seeking an RN Case Manager for an onsite weekend shift to review inpatient and outpatient admission records, collaborate with physicians, and obtain authorizations. The role involves utilization reviews, payer communications, and coordination with Verification and Revenue Cycle teams.

Responsibilities include documenting in STAR, educating patients and families, and participating in peer-to-peer reviews to ensure appropriate admission status and continued stay.

Qualifications

• Current Iowa RN license.
• Minimum of five years of clinical nursing experience.
• BSN or healthcare-related degree preferred.
• Knowledge of insurance eligibility, CMS rules, and utilization review processes.
• Strong clinical judgment, communication, and independent decision-making skills.
• Utilization Review certification within 12 months of hire preferred.
• Mandatory Reporter abuse training within three 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

Clinical nursing

Insurance knowledge

Utilization review

Communication skills

Education

BSN or healthcare-related degree

Job description

Mercy Medical Center is seeking an RN Case Manager for an onsite weekend shift to review inpatient and outpatient admission records, collaborate with physicians, and obtain authorizations. The role involves utilization reviews, payer communications, and coordination with Verification and Revenue Cycle teams.

Responsibilities include documenting in STAR, educating patients and families, and participating in peer-to-peer reviews to ensure appropriate admission status and continued stay.