Registered Nurse, Utilization Coordinator

We are recruiting for a motivated Registered Nurse, Utilization Coordinator to join our team!

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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

(40%)

Compliance

(20%)

Education :

Work Experience :

Licenses :

Knowledge, Skills and Abilities :

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, 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.

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.