Registered Nurse, Utilization Coordinator

Denver Health•Denver, CO

3d•$77,400 - $116,100

About The Position

Denver Health is recruiting a mission-driven Registered Nurse, Utilization Coordinator for its Revenue Integrity department. Under general supervision, the RN Utilization Review Coordinator facilitates appropriate patient status and level of care for commercial insurance, Medicare, Medicaid, and self-pay cases. Reviews are completed according to workflow cadence and to ensure compliance with state, federal, and third-party payer requirements. The coordinator communicates daily and as needed with RN Care Coordinators, Clinical Social Workers, and healthcare teams. The role manages observation and inpatient utilization reviews, assesses medical necessity and level-of-care placement, and documents review findings using approved criteria and department processes. It also coordinates insurance certifications, tracks review responses, and supports regulatory and payer compliance while protecting patient rights and confidentiality.

Requirements

Associate's degree and completion of a nursing education program that satisfies Colorado State Board of Nursing licensing requirements for Registered Nurses.
Three years of clinical experience in a hospital, acute care, home health/hospice, direct care, or case management.
Current Registered Nurse license through the Colorado Department of Regulatory Agencies (DORA).
Knowledge of case management and care coordination principles, programs, and processes in a hospital or outpatient healthcare environment.
Ability to collaborate effectively with people of varied personalities and emotional conditions while maintaining professional composure.
Strong customer service orientation and aptitude.
Problem-solving skills, including the ability to analyze problems, draw relevant conclusions, and devise appropriate courses of action.
Ability to communicate complex or technical information verbally and in writing, and to understand and interpret complex information from others.
Microsoft Office Suite proficiency.
Experience with Windows-based computer programs and ability to use a computer for data analysis and display.

Nice To Haves

Bilingual in English and Spanish.
Experience with medical management platforms used to document care coordination services.

Responsibilities

Manage observation-status patients to assess appropriateness for discharge or conversion to inpatient admission using approved medical necessity criteria throughout the observation stay.
Conduct daily medical necessity reviews of inpatient admissions, transfers, and continued-stay patients using approved criteria.
Initiate the Condition Code 44 process when applicable.
Collaborate with Clinical Documentation Improvement Specialists and physicians to improve documentation accuracy and identify the working MS-DRG and associated geometric mean length of stay.
Conduct proactive medical necessity reviews, as assigned, of cases referred from the Emergency Room, PACU, transfers, and direct admissions from physician offices.
Use the criteria software application to document criteria application, length-of-stay assignments, and variance documentation according to policy.
Initiate Physician Advisor referrals for cases that do not meet criteria for the level of care.
Ensure compliance with state, federal, and payer medical necessity and certification requirements.
Document clinical information required for insurance company certification within payer timeframes.
Collaborate with Clerical Support Staff to ensure insurance reviews are submitted and disposition responses are received.
Document insurance certification activities in assigned locations according to department standards.
Ensure compliance with applicable regulatory requirements and insurance company rules, including Patient Choice, Important Message from Medicare #2, Condition Code 44, and insurance certification processes.
Follow hospital policies, procedures, objectives, safety, environmental, and infection-control guidelines.
Protect patient rights and maintain confidentiality during the case management process.

Benefits

Paid time off starting at 28 days per year, inclusive of vacation, personal/sick time, and seven holidays.
100% paid parental leave for up to six weeks.
Immediate eligibility for retirement plans with employer contributions up to 9.5%.
Medical, dental, and vision plans, plus employer-paid disability and life insurance.
Well-being programs, including an on-site employee fitness center and the RESTORE Center.
Free RTD EcoPass for public transportation.
Childcare discount programs and discounts/perks on brands and travel.
Tuition reimbursement and assistance.
Education, coaching, and professional development through the Workforce Development Center, supporting career growth and advancement.
Professional clinical advancement program and shared governance.
Public Service Loan Forgiveness eligibility, with free student loan coaching and assistance navigating the program.
Eligibility for National Health Service Corps and Colorado Health Service Corps programs.