Registered Nurse, Utilization Coordinator

Denver Health and Hospital Authority • Denver, CO

15d

About The Position

We are recruiting for a motivated Registered Nurse, Utilization Coordinator to join our team! We are here for life’s journey. Where is your life journey taking you? Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all: Humanity in action, Triumph in hardship, Transformation in health. 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.

Requirements

• Associate's Degree Completion of a nursing education program that satisfied the licensing requirements of the Colorado State Board of Nursing for Registered Nurses.
• 1-3 years Three years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required.
• RN-Registered Nurse - DORA - Department of Regulatory Agencies
• 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.

Nice To Haves

• Bilingual in English/Spanish preferred.
• Prefer experience with Medical Management platforms used to document care coordination services.

Responsibilities

• 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%)

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans
• Free RTD EcoPass (public transportation)
• On-site employee fitness center and wellness classes
• Childcare discount programs & exclusive perks on large brands, travel, and more
• Tuition reimbursement & assistance
• Education & development opportunities including career pathways and coaching
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees