ED RN Case Manager Nights

Trinity Health•Des Moines, IA

3d•Onsite

About The Position

This is a full-time night shift position for an RN Case Manager at Mercy Medical Center and Mercy West Lakes. The role involves reviewing inpatient and outpatient admission records for appropriate admission status, collaborating with physicians and Case Management staff, and interacting with insurance providers to obtain authorizations and continued stay approvals. The Case Manager will also work with other departments to establish the correct payer source and document 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.