Registered Nurse, Utilization Coordinator

We are recruiting for a motivated Registered Nurse, Utilization Coordinator to join our team! We are here for lifes journey. Where is your life journey taking you? Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all: Humanity in action, Triumph in hardship, Transformation in health. Department REVENUE INTEGRITY Job Summary Under general supervision, the RN Utilization Review Coordinator will facilitate the appropriate status and level of care. This includes all commercial insurance, Medicare, Medicaid and self-pay. These will be reviewed on a cadence defined in the specific workflow. All Reviews will be done to ensure compliance with all state, federal and third-party payors. They will communicate daily and as needed to the RN Care Coordinator, Clinical Social Worker and healthcare teams. Essential Functions: Status and Level of Care Management Manages observation status patients to determine appropriateness for discharge or conversion to inpatient admission using approved medical necessity criteria continually throughout the observation stay Conducts medical necessity reviews on all inpatient admissions, transfers and continued stay patients using approved medical necessity criteria daily Initiates Condition Code 44 process when applicable Works with the Clinical Documentation Improvement Specialists and physicians to identify opportunities to improve the accuracy of the documentation as well as identify the working MSDRG and associated geometric mean length of stay Conducts proactive medical necessity review of cases being referred from the Emergency Room, PACU, transfers and direct admissions from physician offices to ensure appropriate status and level of care placement , as assigned Uses the criteria software application to document results of criteria application according to the documentation policy, i.e. MCG criteria application, length of stay assignments and variance documentation, etc. Initiates Physician Advisor referrals for any cases not meeting criteria for the level of care Ensures compliance with all state, federal and payor medical necessity and certification requirements (40%) Utilization Review for Insurance Companies Documents clinical information as required for insurance company certification according to required payor timeframe standards Works collaboratively with the Clerical Support Staff to ensure all insurance reviews are received by the insurance company and a disposition response is received Documents all insurance certification activities in the assigned locations according to the department documentation standards (40%) Compliance Ensures compliance with all applicable state and federal regulatory requirements as well as the insurance company rules such as Patient Choice, Important Message from Medicare #2, Condition Code 44, insurance certification processes, etc. Maintains compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines Protects Patient Rights as they pertain to the ethical and legal issues of confidentiality during the case management process (20%) Education: Associate's Degree Completion of a nursing education program that satisfied the licensing requirements of the Colorado State Board of Nursing for Registered Nurses. Required Work Experience: 1-3 years Three years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required. Required Licenses: RN-Registered Nurse - DORA - Department of Regulatory Agencies Required Knowledge, Skills and Abilities: Bilingual in English/Spanish preferred. 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. Microsoft Office Suite required. Experience with windows-based computer programs and ability to use computer for data analysis and data display required. Prefer experience with Medical Management platforms used to document care coordination services. Shift Work Type Regular Salary $75,100.00 - $116,400.00 / 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, Denvers 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 Colorados 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. Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. Applicants will be considered until the position is filled. Denver Health was founded as City Hospital in 1860 to serve the health care needs of the rapidly developing city of Denver. Since then, we have grown alongside the community to become a complete health care system, proudly providing care for all residents -- at every point in their lives. We believe healthy people are the foundation of a vibrant community, and Denver Health has been treating and healing the people of Denver for more than 160 years. Today, Denver Health delivers preventive, primary and acute care services. We are committed to making our community a healthy place to live, work and raise a family. Youll see that commitment in the programs we offer, through the care we provide and in our determination to achieve continuous improvement so our community always has the best care available. As a comprehensive, integrated organization, we provide hospital and emergency care to the public, regardless of ability to pay. This integration promotes continuity of care for each patient and assures health care that is delivered in the most efficient, cost-effective setting. We care for: thirty-three percent of Denver's population annually; Denver Health sees nearly 1,200,000 total patient visits annually. one in three Denver-area children each year. the needs of special populations such as the poor, uninsured, pregnant teens, persons addicted to alcohol and other substances, victims of violence and the homeless. As Colorado's primary safety-net institution, Denver Health has provided uncompensated care and serves as a model for other safety net institutions across the nation.