Weekend RN Case Manager: Utilization & Payer Reviews

Trinity Health Mid-Atlantic; Des Moines (IA); On-site; USD 85,000 - 110,000; Full time

Job summary

Trinity Health is seeking an experienced RN Case Manager to support onsite utilization management on the Des Moines weekend team. This full-time role covers Saturday and Sunday shifts from 7am to 7:30 PM and collaborates with physicians, payers, and care teams to ensure appropriate admission status and continued stay.

The position requires an Iowa RN license with at least five years of clinical nursing experience.

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

Clinical nursing experience

Communication

Independent decision-making

Education

BSN or healthcare-related degree preferred

Job description

Trinity Health is seeking an experienced RN Case Manager to support onsite utilization management on the Des Moines weekend team. This full-time role covers Saturday and Sunday shifts from 7am to 7:30 PM and collaborates with physicians, payers, and care teams to ensure appropriate admission status and continued stay.

The position requires an Iowa RN license with at least five years of clinical nursing experience.