Registered Nurse, Utilization Coordinator

$77,400 - $116,100 / year

We are recruiting for a mission-driven Registered Nurse, Utilization Coordinator 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

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

$77,400.00 - $116,100.00 / 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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This role requires a high degree of coordination with external and internal business partners, including, but not limited to the UnitedHealthcare clinical services inpatient, intake/prior authorizations, appeals and grievance, quality, case and disease management, behavioral health, and other clinical specialties, external HCBS providers and vendors and, or national programs. If you are located in Washington, DC area, you will have the flexibility to telecommute* as you take on some tough challenges. Primary Responsibilities: Intake of provider, care coordinator, and Continuity of Care HCBS (home and community-based service) assisted technology and environmental modifications authorization requests Review and processing of HCBS authorizations including SMW (Services My Way) budget review request Assist case management to determine approval and interventions needed, for the determination of medical necessity, appropriateness of HCBS services Engage with the National Letter Team to complete mailing of member and provider notification of decision Engage / follow-up with Medical Director to provide clinical information needed for review and application of clinical criteria for PDN request Works closely with medical director when issues and concerns regarding the appropriateness, quality or efficiency of care delivery are identified Engage / follow-up with Care Management for assessment of member care needs Extensive knowledge of the continuum of care Participate in planning and attending UM meetings, including CUE and Grand Rounds. Participates in state and internal audits and complies with all UM reporting requirements Always conduct themselves in a professional manner Work closely with the HCBS Review Manager on HCBS issues and concerns Perform additional utilization management related duties as assigned You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: Unrestricted RN license in the District of Columbia 2+ years of clinical experience in health care clinical settings 2+ years working in a managed care setting 2+ years of utilization management experience Demonstrated intermediate-Advanced proficiency experience with Microsoft Office Suite programs (Word, Excel, Outlook) Preferred Qualifications: Experience working with HCBS authorizations and communicating with HCBS providers Demonstrated knowledge of District of Columbia Medicaid Proven knowledge of Utilization Management and authorization processes Experience in a work from home environment Training in Interqual and/or MCG Guidelines Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.