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Rn Utilization Coordinator, Denver Health Medical Plan

Company

Denver Health
Address , Denver, 80204, Co
Employment type FULL_TIME
Salary $76,900 - $115,400 a year
Expires 2023-07-26
Posted at 11 months ago
Job Description
We are recruiting for a RN Utilization Coordinator, Denver Health Medical Plan 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
Managed Care Administration
  • Remote Opportunity. Must Be a Colorado Resident
Job Summary
Under minimal supervision the RN, Utilization Coordinator uses critical clinical thinking skills to perform initial inpatient or outpatient utilization review activities to determine the efficiency, effectiveness and quality of medical and behavioral health services. The RN, Utilization Coordinator, in collaboration with the UM Supervisor, serves as liaison between ordering and service providers and the Health Plan. This position 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 to contract and policy guidelines. Position prepares letters to providers and members to 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. Position communicates with the Medical Director regarding clinical questions and decision-making.
Essential Functions:
  • Clinical reviews are performed within timeliness guidelines for preservice, urgent or concurrent review.
  • May be eligible for remote work based on quality of work and level of experience.
  • All potential denials of service/care are referred to Medical Directors for review in a comprehensive, timely and professional manner
  • 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
  • Mentors and performs peer reviews.
  • Requests additional info from requesting providers as needed
  • Performs clinical review of inpatient or outpatient service request using clinical judgment, nationally accepted clinical guidelines, knowledge of departmental procedures and policies.
  • Creates correspondence to Members and Providers related to clinical determination; adjusts language to appropriate literacy level to support lay person understanding of medical terminology
  • Support and collaborate with the UM and CM Managers and Supervisors in the implementation and management of UM/CM activities
  • Consults on cases with Supervisor, Manager, Director or Medical Director as needed

Education:
  • Bachelor's Degree Required

Work Experience:
  • 1-3 years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required.
  • 1-3 years experience in care coordination or case management required.

Licenses:
  • RN-Registered Nurse - DORA - Department of Regulatory Agencies Required

Knowledge, Skills and Abilities:
  • Experience working with the needs of vulnerable populations who have chronic medical, behavioral health or social needs.
  • 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.
  • 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.
  • Certification in Case Management.
  • Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
  • Prefer experience in health plan case management, care coordination, or member navigation.
  • Home care/field based case management experience.
  • Medicaid and Medicare Managed Care experience.
  • Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment.
Shift
Work Type
Regular
Salary
$76,900.00 - $115,400.00 / yr
Benefits
  • State-of-the-art facilities
  • Immediate retirement plan matching
  • Public Service Loan Forgiveness (PSLF) eligible employer
  • Professional clinical advancement program
  • Education opportunities
  • National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer
  • Shared leadership and advancement opportunity
  • Outstanding benefits
  • Participation in evidence-based projects
  • Competitive pay
Our Values
  • Belonging
  • Transparency
  • Respect
  • Accountability
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.
As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.
Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).

Denver Health values the unique ideas, talents and contributions reflective of the needs of our community. For read more about our commitment to diversity visit:
https://www.denverhealth.org/for-professionals/careers/diversity-and-inclusion