RN Registered Nurse, Utilization Coordinator Denver Health Medical Plan - Remote (Must be a Colorado Resident)

We are recruiting for a motivated RN Registered Nurse, Utilization Coordinator Denver Health Medical Plan - Remote (Must be a Colorado Resident) to join our team!

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Department

Managed Care Administration

*Must Be a Colorado Resident

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.

Shift

Days (United States of America)

Work Type

Regular

Salary

$69,900.00 - $108,300.00 / yr

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 brand