Case Manager-Utilization Review-RN

Trinity Health • Mason City, IA

1d

About The Position

The Utilization Review Case Manager is responsible for case screening, obtaining insurance approvals, ensuring timely services, and facilitating discharge and transition to appropriate services. The role helps the organization comply with CMS rules and regulations, conditions of participation, and commercial payer guidelines to prevent denials and revenue loss. It supports patient outcomes through effective use of care plans, managed care concepts, appropriateness criteria, resource management, community resources, and collaboration with other clinical disciplines.

The position is full-time, Monday through Friday on the day shift, with no holidays.

Requirements

• Licensed registered nurse in the state of Iowa.
• Bachelor's degree required.
• Five years of registered nurse experience involving community contact, knowledge of managed care, resource utilization criteria, Medicaid, and insurance coverage for acute care and skilled care.
• Knowledge and skills with data systems, continuous quality improvement (CQI), and community healthcare resources.
• Ability to work independently, analyze data, exercise judgment, and arrive at conclusions.
• Ability to establish and maintain working relationships.
• Assertiveness and critical-thinking ability.
• Ability to communicate effectively and tactfully both verbally and in writing.
• Initiative, judgment, discretion, and decision-making skills.
• Ability to plan, prioritize, organize, and direct the work of others.
• Willingness to accept responsibility and be accountable for one's actions.
• Ability to read, write, and/or speak English.
• Provide proof of Basic Life Support (BLS Provider-American Heart Association or Professional Rescuer-American Red Cross) before employment or within 30 days of hire, and maintain current status.
• Provide proof of Mandatory Reporting for Child and Dependent Adult Abuse training before employment or within 6 months of hire, and maintain current status.
• Successful completion of references, background checks, pre-employment physical, drug screen, and post-offer exam.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Utilization management-focused certifications recognized in Iowa.
• Case management experience.

Responsibilities

• Screen cases.
• Obtain insurance approvals.
• Ensure timely services.
• Facilitate discharge and transition to appropriate services.
• Assist the organization in complying with CMS rules and regulations, conditions of participation, and commercial payer guidelines.
• Support patient outcomes through care plans, managed care concepts, appropriateness criteria, resource management, community resources, and collaboration with other clinical disciplines.
• Plan, prioritize, organize, and direct the work of others.

What This Job Offers

• Job Type: Full-time