Registered Nurse, Utilization Coordinator - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement)
About The Position
We are recruiting for a mission-driven Registered Nurse, Utilization Coordinator - Denver Health Medical Plan to join our team! At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey. This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week. 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. Conveys 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.
Requirements
- 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
- 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
- RN-Registered Nurse - DORA - Department of Regulatory Agencies required
- 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
Nice To Haves
- 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
Responsibilities
- 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.
- Consults on cases with Supervisor, Manager, Director or Medical Director. Requests additional info from requesting providers, as needed.
- Creates correspondence to Members and Providers related to clinical determination; adjusts language to appropriate literacy level to support lay person understanding of medical terminology.
- Routes potential denials of service/care are referred to Medical Directors for review in a comprehensive, timely and professional manner.
- Support and collaborate with the UM and CM Managers and Supervisors in the implementation and management of UM/CM activities.
- Mentors and performs peer reviews.
- 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.
Benefits
- Generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs.
- Tuition assistance, career advancement pathways, and professional development
- Meaningful financial advantages through loan forgiveness eligibility and employer contributions.
- 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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
