Registered Nurse, Utilization Coordinator - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement)

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We are recruiting for a mission-driven Registered Nurse, Utilization Coordinator - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement) 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 Managed Care Administration * Must Live in Colorado * This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week. Job Summary 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. Convey 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. Essential Functions : 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. (30%) Consults on cases with Supervisor, Manager, Director or Medical Director. Requests additional info from requesting providers, as needed. (20%) Creates correspondence to Members and Providers related to clinical determination; adjusts language to appropriate literacy level to support lay person understanding of medical terminology. (15%) Routes potential denials of service/care are referred to Medical Directors for review in a comprehensive, timely and professional manner. (10%) Support and collaborate with the UM and CM Managers and Supervisors in the implementation and management of UM/CM activities. (10%) Mentors and performs peer reviews. (10%) 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. (5%) Education : 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 Work Experience : 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 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 Licenses : RN-Registered Nurse - DORA - Department of Regulatory Agencies required Knowledge, Skills and Abilities : 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 * This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week. Shift Days (United States of America) Work Type Regular Salary $71,400.00 - $107,100.00 / yr

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