Utilization Review Nurse, Managed Care Administration

*Must be Colorado resident.Job Summary

Under minimal supervision the Utilization Review Nurse 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 Clinical Reviewer II, 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.

Responsibilities1. Performs clinical review of inpatient or outpatient service requests, using clinical judgment, nationally accepted clinical guidelines, knowledge of departmental procedures and policies. 2. Clinical reviews are performed within timeliness guidelines for preservice, urgent or concurrent review. 3. Requests additional info from requesting providers as needed 4. Creates correspondence to Members and Providers related to clinical determination; adjusts language to appropriate literacy level to support lay person understanding of medical terminology 5. Consults on cases with Supervisor, Manager, Director or Medical Director as needed 6. Mentors and performs peer reviews of Clinical Reviewer I staff as directed by Supervisor 7. All potential denials of service/care are referred to Medical Directors for review in a comprehensive, timely and professional manner 8. Support and collaborate with the UM and CM Managers and Supervisors in the implementation and management of UM/CM activities 9. 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 10. Other duties as assigned.

Knowledge, Skills and Abilities1. Bilingual in English/Spanish preferred. 2. Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment. 3. 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. 4. Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action. 5. 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. 6. Prefer experience in health plan case management, care coordination, or member navigation. 7. Certification in Case Management. 8. Home care/field based case management experience. 9. Medicaid and Medicare Managed Care experience. 10. Experience working with the needs of vulnerable populations who have chronic medical, behavioral health or social needs.
Knowledge, Skills and Abilities1. Bilingual in English/Spanish preferred. 2. Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment. 3. 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. 4. Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action. 5. 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.

Computers and Technology1. Microsoft Office Suite required. 2. Experience with windows-based computer programs and ability to use computer for data analysis and data display required. 3. Prefer experience with Medical Management platforms used to document care coordination services.

Certificates, Licenses and Registration1. Active Registered Nurse (RN) License in the State of Colorado or a participating compact state. All Certifications and Licenses required for this job must be kept current as a condition of continued employment. 2. Certification in Case Management preferred.


Computers and Technology1. Microsoft Office Suite required. 2. Experience with windows-based computer programs and ability to use computer for data analysis and data display required. 3. Prefer experience with Medical Management platforms used to document care coordination services.
EducationAssociate's Degree (Required) 1. Completion of an accredited nursing education program and satisfies the licensing requirements of the Colorado State Board of Nursing for Registered Nurses required. 2. Bachelor’s degree in Nursing (BSN) preferred. 3. Three years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required. 4. Prefer experience in health plan case management, care coordination, or member navigation. 5. Home care/field based case management experience preferred. 6. Medicaid and Medicare Managed Care experience preferred. 7. Experience working with the needs of vulnerable populations who have chronic medical, behavioral health or social needs preferred.


Credentials1. Registered Nurse (Required)

Location
Denver Health Medical Plan

Shift
Days

Work Type
Full time

Pay Range

Minimum: $31.27

Midpoint: $40.17

Maximum: $49.05

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, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver’s 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.

As Colorado’s primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.

Located just south of 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 is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.”