Utilization Review RN Flex

Job Overview

The Utilization Review RN participates as a member of a multidisciplinary team to support medical necessity reviews, ensure compliance, and actively participate in denial mitigation. It is a collaborative approach that uses pre-established guidelines and criteria to perform review activities to ensure the proper utilization of hospital services and payment of those services by Medicare, Medicaid, and other third-party payors.

Department Name: Utilization Review Job Status: flex, not eligible for benefits Shift: variable - must have availability to work at least 24 hours per pay period. Shifts may include dayshift, evening shift, and weekend shifts, depending on unit staffing needs.

This position will be primarily remote but there may be occasions when you are expected to work onsite at one of the Children's Hospital Colorado locations so all candidates must either live in Colorado already or be willing to relocate before starting. The specific details will be discussed in the interview process, and subject to change at our discretion.

Duties & Responsibilities

An employee in this position may be called upon to do any or all the following essential functions. These examples do not include all the functions which the employee may be expected to perform.

• Assesses all new inpatient admissions for identification of status and medical necessity for admission; communicates clinical review process with appropriate Payors.
• Assesses the continuity of care in conjunction with the Case Managers regarding the continued medical necessity of hospitalization and the status of the discharge plan; communicates this to the appropriate payors.
• Coordinates with other members of the healthcare team to help identify and control inappropriate resource utilization.
• Conducts concurrent admission and continued stay reviews based on appropriate utilization review criteria.
• Utilizes information provided by Patient Access regarding authorized length of stay and follows up with third-party payors on an ongoing basis, documents communications regarding continued authorizations.
• Follows up on denials communicated to the department and works with the revenue cycle staff to assist with appeals.
• Maintains and demonstrates appropriate clinical knowledge to assist physicians in providing documentation of severity of illness and intensity of service to assure that criteria for acute hospitalization are met.
• Employees are expected to comply with all regulatory requirements, including CMS and Joint Commission Standards.

Minimum Qualifications

Education

Bachelor of Science in Nursing (BSN)

Experience

Three years of recent clinical or case management experience that includes recent UR experience in a hospital or with a Third-Party Payor Certification(s): BLS/CPR from the American Heart Association with at least 6 months left before expiration is required upon hire. Licensure(s): Registered Nurse License

Salary Information

Pay is dependent on applicant's relevant experience. Hourly Rate of Pay: $50.68

Benefits Information

As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid sick leave and a robust wellness program.

As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April.

Children’s Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year.

EEO Statement

It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information. The position is expected to stay open until the posted close date. Please submit your application as soon as possible as the posting is subject to close at any time once a sufficient pool of qualified applicants is obtained.

Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of attendance at or graduation from an educational institution. You will not be penalized for redacting or removing this information.

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