Case Manager RN
About The Position
The RN Case Manager is responsible for reviewing inpatient and outpatient admission records to ensure appropriate admission status at Mercy Medical Center and Mercy West Lakes. This role involves collaboration with the attending physician and Case Management staff, utilizing admission criteria guidelines and a second-level physician review process when necessary. The Case Manager also interacts with insurance providers to secure authorization and continued stay approval. Collaboration with the Verification department, Revenue Cycle, and Medical Eligibility teams is crucial to establish the correct payer source for patient stays and document these interactions in the STAR admitting system.
Requirements
- Current Iowa RN license.
- Minimum of five (5) years of clinical nursing experience.
- Knowledge of insurance eligibility, CMS rules, and utilization review processes across the continuum of care.
- Strong clinical judgment, communication, and independent decision-making skills.
- Completion of Mandatory Reporter abuse training within three (3) months of hire.
Nice To Haves
- BSN or healthcare-related degree preferred.
- Utilization Review certification within 12 months of hire preferred.
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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
