Utilization Review RN

Trinity Health•Des Moines, IA

1d•Onsite

About The Position

The Utilization Review RN reviews inpatient and outpatient admission records at Mercy Medical Center and Mercy West Lakes to determine appropriate admission status. The RN works with attending physicians and Case Management staff, applies admission criteria and uses a second-level physician review process when appropriate. The role also works with insurance providers to obtain admission authorization and continued-stay approval, and collaborates with Verification, Revenue Cycle, and Medical Eligibility teams to establish the correct payer source and document interactions in the STAR admitting system. This is a full-time, onsite position in Des Moines, Iowa, with a flexible day shift from 7:00 AM to 3:30 PM. Reviews may be concurrent or post-discharge. The RN applies Milliman CareGuidelines and relevant hospital, regulatory, and payer requirements; communicates status changes; documents reviews and payer interactions; and supports denial, appeal, and audit processes. General office duties include filing, data retrieval, and computer use.

Requirements

Current registered nurse licensure in the State of Iowa.
Five years of clinical nursing experience.
Completion of Mandatory Reporter abuse training specific to the population served within three months of hire.
Knowledge of insurance eligibility requirements for ambulatory, observation, surgical, acute care, subacute, and continuum-of-care services.
Ability to manage complex management and clinical situations.
Ability to work independently and exercise judgment to resolve issues.

Nice To Haves

Bachelor of Science in Nursing or a degree in a healthcare-related field.
Specialty certification in Utilization Review within 12 months of hire.

Responsibilities

Review inpatient and outpatient records for admission status and conduct admission reviews under the Utilization Management Plan.
Apply Milliman CareGuidelines and hospital, regulatory, and payer criteria to determine appropriate admission status.
Discuss cases with attending physicians to clarify or correct status and arrange second-level physician review when indicated.
Communicate concurrent status changes to Case Management and notify Admitting of status changes or discrepancies.
Provide patients and families with required Notices of Status Change and explain the change when indicated.
Accurately document admission criteria, status, and communications in the medical record and STAR system.
Collaborate with the Post Denials team on potential appeals or downgrades and document findings in STAR.
Review admission records for status orders consistent with Centers for Medicare & Medicaid Services rules and guidelines.
Monitor patient insurance coverage in STAR and communicate updates to the Verification Department.
Provide requested clinical information to insurance payers promptly through queries, fax, or portals to help prevent technical denials.
Enter authorizations, approvals, and denials into STAR and communicate relevant changes to Case Management.
Support attending physicians in peer-to-peer discussions with insurers regarding admissions, continued stays, or status.
Route denial letters and faxes to the Conifer Appeal Department and document them in STAR.
Work with Medical Records and Admitting to monitor observation outliers and status discrepancies.
Collaborate with the Recovery Audit Contractor Coordinator and Conifer on Medicare and Medicaid RAC denial management.
Perform general office duties, including filing, data retrieval, and computer use.