Case Manager RN

Employment Type: Full time Shift: Description: RN Case Manager (Onsite) Shift: Monday-Friday (8 hours) No Weekends 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. Qualifications Current Iowa RN license. Minimum of five (5) years of clinical nursing experience. BSN or healthcare-related degree preferred. Knowledge of insurance eligibility, CMS rules, and utilization review processes across the continuum of care. Strong clinical judgment, communication, and independent decision-making skills. Utilization Review certification within 12 months of hire preferred. Completion of Mandatory Reporter abuse training within three (3) months of hire. Work Environment & Physical Requirements Primarily office-based with computer, phone, and documentation tasks. Light physical activity with occasional lifting; use of assistive devices and additional personnel as required. Visual acuity sufficient to review medical records and electronic systems. Ability to work collaboratively in a fast-paced, high-stress healthcare environment while maintaining professionalism and courtesy. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.