Registered Nurse, Utilization Coordinator

Denver Health and Hospital Authority•Denver, CO

About The Position

The RN Utilization Review Coordinator works under general supervision to facilitate appropriate patient status and level of care for commercial insurance, Medicare, Medicaid, and self-pay cases. Reviews are conducted according to the applicable workflow cadence and must comply 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 status and reviews inpatient admissions, transfers, continued stays, and other assigned referrals for medical necessity and appropriate placement. It also supports documentation accuracy, insurance certification, regulatory compliance, and protection of patient rights throughout the case management process.

Requirements

Associate's degree.
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 with people with varied personalities and emotional conditions while maintaining professional composure.
Strong customer service orientation and aptitude.
Problem-solving skills, including the ability to analyze problems systematically, draw relevant conclusions, and devise appropriate courses of action.
Ability to communicate complex or technical information verbally and in writing in an understandable manner, and to understand and interpret complex information from others.
Proficiency with Microsoft Office Suite.
Experience with Windows-based computer programs and ability to use a computer for data analysis and display.

Nice To Haves

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

Responsibilities

Manage observation-status cases to determine whether discharge or conversion to inpatient admission is appropriate, applying approved medical necessity criteria throughout the observation stay.
Conduct daily medical necessity reviews for 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, for cases referred from the Emergency Room, PACU, transfers, and direct admissions from physician offices.
Use criteria software to document results according to documentation policy, including criteria application, length-of-stay assignments, and variance documentation.
Refer cases to a Physician Advisor when they do not meet criteria for the level of care.
Ensure compliance with state, federal, and payer medical necessity and certification requirements.
Document clinical information for insurance company certification within required payer timeframes.
Work 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.
Follow applicable state and federal regulations, insurance company rules, and hospital policies and procedures, including requirements involving Patient Choice, Important Message from Medicare #2, Condition Code 44, and insurance certification.
Maintain compliance with hospital safety, environmental, and infection control guidelines.
Protect patient rights, including confidentiality and related ethical and legal obligations during case management.
Communicate daily and as needed with RN Care Coordinators, Clinical Social Workers, and healthcare teams.

Benefits

Paid time off starting at 28 days per year, including vacation, personal/sick time, and seven holidays.
100% paid parental leave for up to six weeks.
Immediate retirement plan eligibility with employer contributions up to 9.5%.
Medical, dental, and vision plans.
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.
Discounts and perks on brands, travel, and more.
Tuition reimbursement and assistance.
Education, coaching, and professional development through the Workforce Development Center.
Career advancement pathways and a professional clinical advancement program.
Shared governance opportunities.
Public Service Loan Forgiveness eligible employer, with free student loan coaching and assistance navigating the PSLF program.