Registered Nurse, Utilization Coordinator - Hybrid

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Department

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:

• Associates 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 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

Salary

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 185000 individuals and 67000 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.