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Insurance Utilization Reviewer Jobs in Iowa (NOW HIRING)

Trinity Health

Utilization Review RN

Des Moines, IA · On-site

Interacts with insurance providers to obtain authorization and continued stay approval for ... Conducts admission review per the Utilization Management Plan to ensure that the hospitalization is ...

Trinityhealth

Utilization Review RN

Des Moines, IA

Interacts with insurance providers to obtain authorization and continued stay approval for ... Conducts admission review per the Utilization Management Plan to ensure that the hospitalization is ...

Trinity Health

Utilization Review RN

Des Moines, IA · On-site

Interacts with insurance providers to obtain authorization and continued stay approval for ... Conducts admission review per the Utilization Management Plan to ensure that the hospitalization is ...

HealthCheck360

Utilization Management Assistant

Dubuque, IA · On-site

$39K - $45K/yr

... insurance verification, LPN, CNA, Medical Assistants, or individuals with a background in customer ... The Utilization Management Assistant answers first level calls in Utilization Review for ...

HealthCheck360

Utilization Management Assistant

Dubuque, IA · On-site

$39K - $45K/yr

... insurance verification, LPN, CNA, Medical Assistants, or individuals with a background in customer ... The Utilization Management Assistant answers first level calls in Utilization Review for ...

HealthCheck360

Utilization Management CNA

Dubuque, IA · On-site

... insurance verification, LPN, CNA, Medical Assistants, or individuals with a background in customer ... The Utilization Management Assistant answers first level calls in Utilization Review for ...

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Insurance Utilization Reviewer information

What are the key skills and qualifications needed to thrive as an Insurance Utilization Reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What are some common challenges faced by Insurance Utilization Reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What are Insurance Utilization Reviewers?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.
What are popular job titles related to Insurance Utilization Reviewer jobs in Iowa? For Insurance Utilization Reviewer jobs in Iowa, the most frequently searched job titles are:
What job categories do people searching Insurance Utilization Reviewer jobs in Iowa look for? The top searched job categories for Insurance Utilization Reviewer jobs in Iowa are:
What cities in Iowa are hiring for Insurance Utilization Reviewer jobs? Cities in Iowa with the most Insurance Utilization Reviewer job openings:
Insurance Utilization Reviewer jobs near you
Utilization Review RN

Utilization Review RN

Trinity Health

Des Moines, IA • On-site

Full-time

Posted 5 days ago

Trinity Health rating

6.5

Company rating: 6.5 out of 10

Based on 353 frontline employees who took The Breakroom Quiz

605th of 890 rated healthcare providers

Job description

Employment Type:
Full timeShift:
Day Shift
Description:
At MercyOne, health care is more than just a doctor's visit or a place to go when you need medical attention. Our Mission is based on improving the health of our communities - that means not only when you are sick but keeping you well.
MercyOne Central Iowa sets the standard for personalized and radically convenient care in the Des Moines metro area and surrounding counties. MercyOne Des Moines Medical Center, founded by the Sisters of Mercy in 1893, is the longest continually operating hospital in Des Moines and Iowa's largest medical center, with 802 beds available. The hospital is one of the Midwest's largest referral centers.
With more than 7,000 colleagues and a medical staff of almost 1,500 physicians and allied health professionals, MercyOne Central Iowa is one of Iowa's largest employers.
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.
Shift: Full-Time Days | Flexible Day Shift (7:00 AM - 3:30 PM)
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.
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.

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About Trinity Health

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Trinity Health Ann Arbor is a 537 -bed teaching hospital located on 340 acre campus. Recognized by IBM Watson as a Top 100 Hospital and #1 Teaching Hospital, Trinity Health Ann Arbor has been a leading health care provider for more than 100 years. Trinity Health has received numerous local and national awards in recognition of our leadership, quality outcomes, and clinical excellence.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Livonia, MI, US

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