RN Registered Nurse, Utilization - Denver Health Medical Plan (Must Live In Colorado. Weekly On Site Requirement.)
Core
RN Utilization Coordinator performing clinical review of inpatient or outpatient service requests to determine efficiency, effectiveness, and quality of medical and behavioral health services.
Role type
Registered Nurse (Utilization Management)
Builds
Clinical determination decisions and service approval/denial for health plan members and providers
Domain
Healthcare / Managed Care Administration
Required skills
Clinical judgment, knowledge of clinical guidelines, case management principles, regulatory requirements knowledge, inter-rater reliability testing, professional nursing standards of practice
Preferred skills
Medicaid and Medicare Managed Care experience, home care/field-based case management, working with vulnerable populations with chronic medical/behavioral health needs, Case Management certification
Technologies
None stated
Responsibilities
Perform clinical review of service requests using clinical judgment and guidelines; Consult with supervisors and medical directors on complex cases; Create correspondence to members and providers adjusting language for literacy; Route potential denials to Medical Directors; Support implementation of UM/CM activities; Mentor and perform peer reviews
Seniority
Mid-level (1-3 years experience)