RN Utilization Review - Denver Health Medical Plan (Must Live in Colorado)

Job Summary

Under general supervision the RN, Utilization Coordinator performs initial inpatient or outpatient utilization review activities to determine the efficiency, effectiveness and quality of medical and behavioral health services.

In collaboration with the UM Supervisor, serves as liaison between ordering and service providers and the Health Plan. Makes medical determination decisions within defined protocols based on review of the service requests, clinical and non-clinical data, Member eligibility, and benefit levels in accordance with contract and policy guidelines.

Convey approval or denial of requested services, identifies and reports on specific cases, and provides information regarding utilization management requirements and operational procedures to members, providers and facilities.

Essential Functions :

• Performs clinical review of inpatient or outpatient service request using clinical judgment, nationally accepted clinical guidelines, knowledge of departmental procedures and policies within timeliness guidelines for preservice, urgent or concurrent review. (30%)
• Consults on cases with Supervisor, Manager, Director or Medical Director. Requests additional info from requesting providers, as needed. (20%)
• Creates correspondence to Members and Providers related to clinical determination; adjusts language to appropriate literacy level to support lay person understanding of medical terminology. (15%)
• Routes potential denials of service / care are referred to Medical Directors for review in a comprehensive, timely and professional manner. (10%)
• Support and collaborate with the UM and CM Managers and Supervisors in the implementation and management of UM / CM activities. (10%)
• Mentors and performs peer reviews. (10%)
• Participates in ongoing education and training related to health plan benefits and limitations, regulatory requirements, clinical guidelines, inter-rater reliability testing, community standards of patient care, and professional nursing standards of practice. (5%)

Education :

Associate's Degree Completion of a nursing education program that satisfies the licensing requirements of the Colorado State Board of Nursing for Registered Nurses, required.

Work Experience :

• 1-3 years clinical experience in a hospital, acute care, home health / hospice, direct care or case management required OR
• 1-3 years experience in care coordination, case management or member navigation required
• Medicaid and Medicare Managed Care experience preferred
• Home care / field-based case management, or working with the needs of vulnerable populations who have chronic medical, behavioral health or social needs preferred
• Certification in Case Management preferred

Licenses :

RN-Registered Nurse - DORA - Department of Regulatory Agencies required

Knowledge, Skills and Abilities :

• Knowledge and understanding of case management / coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment.
• Effectively collaborate with and respond to varied personalities in differing emotional conditions, and maintain professional composure at all times.

Strong customer service orientation and aptitude.

• Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
• Ability to communicate verbally and in writing complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.

Shift

Work Type

Regular

Salary

$78,802.00 - $118,203.00 / yr

Benefits

Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.

5%, and generous medical plans

Free RTD EcoPass (public transportation)

On-site employee fitness center and wellness classes

Childcare discount programs & exclusive perks on large brands, travel, and more

Tuition reimbursement & assistance

Education & development opportunities including career pathways and coaching

Professional clinical advancement program & shared governance

Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program

National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

Respect

Belonging

Accountability

Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured.

Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).

Denver Health values the unique ideas, talents and contributions reflective of the needs of our community. For more about our commitment to diversity visit :

Applicants will be considered until the position is filled.