RN Registered Nurse, Utilization - Denver Health Medical Plan (Must Live In Colorado. Weekly On Site Requirement.)

Denver Health Lincoln Park, CO 80203, US

We are recruiting for a mission-driven RN Registered Nurse, Utilization - Denver Health Medical Plan (Must Live In Colorado. Weekly On Site Requirement.) to join our team!

We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey.

Our Values

Respect | Belonging | Accountability | Transparency

Department

Managed Care Administration

* Must live in Colorado

* This is a hybrid role with a requirement of being in the office 2 days per week.

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.

* Must live in Colorado

* This is a hybrid role with a requirement of being in the office 2 days per week.

Shift

Days (United States of America)

Work Type

Regular

Salary

$71,400.00 - $107,100.00 / yr

Benefits

At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future — with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development — while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you’re joining a mission-driven organization that invests in you.

Here is a small list of our benefit programs:

Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays
100% paid parental leave up to 6 weeks
Immediate eligibility for retirement plans with employer contribution up to 9.5%
Generous medical, dental, vision plans in addition to employer paid disability and life insurance.
Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center
Free RTD EcoPass (public transportation)
Childcare discount programs & exclusive perks on large brands, travel, and more
Tuition reimbursement & assistance
Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways
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

About Denver Health

Denver Health is an integrated, high-quality academic healthcare 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, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation.

As Colorado’s primary, and essential, safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each 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. All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Applicants will be considered until the position is filled.

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