General Requirements:  

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.

ESSENTIAL FUNCTIONS:

• Conducts admission review per the Utilization Management Plan to ensure that the hospitalization is approved based on established criteria. Reviewing may be both concurrent or post discharge.
• Carries out hospital programs and principles of utilization review in compliance with hospital policies and external regulatory agencies Peer Review Organization (PRO), Joint Commission, and multiple payer defined criteria for eligibility.
• Applies Milliman Careguidelines Criteria for appropriate status determination.
• Engages in discussion with the attending physician for clarification and/or status correction.
• Engages second level physician review as indicated to support the appropriate status.
• Ensures timely communication with Case Management staff for all concurrent status changes.
• Administers Notice of Status Change to the patient/family when indicated. Provides education and information for the patient/family for clarification of the change.
• Documents in the Medical Record Utilization Management forms accurately to reflect the appropriate admission criteria and appropriate status along with any communications.
• Collaborates with MercyOne Post Denials team to determine potential appeals or downgrades and documents in STAR.
• Ensures timely notification to Admitting of status of change or status discrepancies identified.
• Reviews the records on admission for status orders present addressing Center for Medicare Services rules and guidelines around admission status.
• Monitors insurance coverage for patients in the STAR admitting/financial system and communicates any updates to the Verification Department.
• Provides clinical information as request from the insurance payer via the query, fax or portal in a timely manner to prevent technical denials.
• Enters authorization, approvals and denials into the STAR systems and communicates pertinent changes to Case Management.
• Engages the attending physician to advocate and communicate via Peer to Peer Review for discussion with insurance for admission, continued stay or status when required.
• Reviews denial letters/faxes received in Care Coordination Department and direct to Conifer Appeal Department for appeal. Documents in the STAR system.
• Collaborates in monitoring and addressing observation outliers and status discrepancies with Medical Records Department and Admitting Department.
• Collaborates with the Recovery Audit Contractor (RAC) Coordinator and Conifer for Medicare/Medicaid RAC Denials management.

MARGINAL FUNCTIONS:

General office duties of filing, data retrieval and computer use.

MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

• Current licensure as a registered nurse in the State of Iowa.
• Five (5) years clinical nursing experience.
• Bachelor of Science - Nursing or degree in healthcare-related field preferred.
• Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire.
• Knowledge of eligibility requirements for insurance coverage with respect to health care services: ambulatory, observation stays, surgical, acute care, subacute and continuum of care services.
• Demonstrated ability to manage complex management and clinical situations. Ability to work within a function independently exercising judgement to reach resolutions to issues.
• Specialty certification in Utilization Review within 12 months of hire preferred.

Colleagues of MercyOne Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout the system!  

Visit MercyOne Careers to learn more about the benefits, culture, and career development opportunities available to you at MercyOne Health System’s circle of care. 

Want to learn more about MercyOne Des Moines? Click here: Find a Location Des Moines, Iowa (IA), MercyOne Des Moines  

Iowa’s capital city offers a balanced urban-suburban experience with a cost of living below the national average. It’s ranked among the top safest large metros and boasts strong education options, including highly rated public schools, private academies and nearby universities like Drake University and Grand View University. Cultural highlights include theaters, museums, music festivals and a thriving food scene, while outdoor enthusiasts enjoy extensive parks and bike trails. Located just minutes from the airport, Des Moines offers easy access to regional attractions and a welcoming, community-focused atmosphere.  

MercyOne Des Moines Medical Center is a leading 656-bed acute‑care, not‑for‑profit Catholic hospital and one of Iowa’s largest employers. Founded in 1893, it’s the longest continuously operating hospital in Des Moines. Accredited as a Top Regional Hospital by U.S. News & World Report, named one of Becker’s 100 Great Hospitals, and ranked among the top 50 cardiovascular hospitals by IBM Watson Health. With Joint Commission Gold Seal accreditation, stroke and heart care awards, CAP-accredited lab and ACS-certified Cancer Center, this flagship facility offers comprehensive services including robotic surgery, cancer care, neurosciences, rehab, emergency/trauma, maternity, behavioral health and a robust nursing excellence program.