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

About the role

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!

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 and discharge planning.
• 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.

Requirements

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

Qualifications

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.

Able 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.

Skills

Knowledge of nationally accepted clinical guidelines.

Ability to work independently and manage multiple tasks simultaneously.

Excellent communication and interpersonal skills.

Benefits

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%

Comprehensive 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

National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) 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