Utilization Review Registered Nurse (RN)

Trinity Health•Des Moines, IA

20h

About The Position

Utilization Review RN General Summary: Responsible for the review of inpatient and outpatient admission records for appropriate admission status at Mercy Medical Center and Mercy West Lakes. Works in collaboration with the attending physician and the Case Management staff utilizing admission criteria guidelines-and second level physician review process when appropriate. Interacts with insurance providers to obtain authorization and continued stay approval for admission. Collaborates with the Verification department, Revenue cycle and Medical Eligibility to facilitate the establishment of the correct payer source for patient stay and the documentation of the interactions in the STAR admitting system Key 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.

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.