Utilization Management/Case Management Leader

At Mahaska Health the Utilization Management Case Management Lead (UMCM Lead) oversees the organization's Utilization Review and Discharge Planning functions to ensure full compliance with CMS Conditions of Participation and Joint Commission Standards. This role is responsible for implementing and annually reviewing the Utilization Management Plan, coordinating the Utilization Management Committee, and ensuring that patient care needs both during hospitalization and after discharge are appropriately assessed and met.

The UMCM Lead supports a comprehensive Case Management/Utilization Program that integrates utilization review, discharge planning, and resource management. Through collaborative practice, this role promotes high‑quality care, efficient resource use, reduced length of stay, cost‑effective operations, and optimal patient outcomes.

Essential job responsibilities include but are not limited to,

• A Coordinates with admitting providers to determine the appropriate level of care for each patient throughout their hospitalization.
• Conducts comprehensive admission, concurrent, and retrospective utilization reviews for all assigned patients, applying nationally accepted criteria and medical‑necessity screening tools to validate appropriate placement.
• Collaborates with payers to obtain authorization for clinical services through effective communication and adherence to the Utilization Review Plan.
• Provides timely updates to insurance companies regarding patient status to support appropriate reimbursement and informs physicians of allowable Lengths of Stay (LOS).
• Completes PPS data entry accurately and within required timeframes.
• Partners with interdisciplinary team members to ensure seamless transitions of care from Mahaska Health to external agencies. Coordinates patient transfers and maintains required documentation to support continuity of care, regulatory compliance, and effective discharge planning.
• Leads the denial and appeal process, including reviewing payer denials, collaborating with clinical staff, preparing additional documentation, and facilitating peer‑to‑peer reviews when needed.
• Performs retrospective reviews to identify causes of avoidable days and opportunities for improvement.
• Works with inpatient peers to ensure timely delivery of denial letters to patients, supporting efficient care transitions.
• Researches denial claims and submits supplemental clinical information for reconsideration when appropriate.
• Identifies and resolves delays in care by collaborating closely with nursing staff and attending physicians.
• Proactively tracks avoidable days and addresses barriers to promote efficient patient flow and optimal resource utilization.
• Contributes to the development of the Utilization Management Plan and Mahaska Health's Care Management practices in alignment with CMS Conditions of Participation (CoPs).
• Ensure EMR documentation accurately reflects medical necessity for inpatient or observation status, maintaining compliance with regulatory and organizational standards.
• Maintains high‑quality documentation practices, ensuring clarity, conciseness, and adherence to laws, regulations, and established criteria such as MCG guidelines. Documentation responsibilities include:
  • Ensuring physicians write valid orders for the appropriate level of care
  • Recording potential denials and appeals
  • Collaborating with external case managers and communicating with patients and families
  • Supporting organizational quality and compliance goals
• Uses documentation to analyze utilization patterns and trends, identify issues, and participate in data collection for special studies or routine monitoring activities.
• Communicates findings from post‑service external audits to leadership, supporting both immediate decision‑making and long‑term strategic planning.
• Educating medical staff and other team members on changes related to utilization review requirements and processes.
• Participates in the Medical Inpatient Committee, providing relevant information and implementing committee recommendations.
• Ensures patient admission criteria are reviewed by the Hospitalist when criteria are unclear or in question.

Job Requirements include but are not limited to,

• A graduate from an accredited school of nursing and currently licensed as a Registered Nurse in the state of Iowa (or) a graduate from an accredited school of nursing and currently licensed as a Registered Nurse able to work in the state of Iowa. Preference given to BSN or MSN.
• Prior experience in case management, utilization review, or care coordination preferred.
• Knowledge of URDP regulations and requirements or relevant clinical experience that supports the learning and competencies required for this role.
• Skilled in crisis intervention, triage, discharge planning, and case management practices.
• Demonstrated leadership or management abilities, with the capacity to guide processes and collaborate across disciplines.
• Experience in Quality Management, Process Improvement, or CMS review activities.
• Excellent communication, critical thinking, and problem‑solving skills, with the ability to work effectively in complex clinical environments.
• Strong analytical skills.