Utilization Review RN

SUMMARY
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: part time, 24 hours per week, eligible for benefits
Shift: Monday through Friday mostly. May work days or evenings and some weekends required as needed.

Will be trained to perform all responsibilities within the department, covering all shifts/roles as necessary. More details will be shared in the interview process.

This position will be primarily remote but there may be occasions when you are expected to work onsite at one of the CHCO locations. 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.

1. Assesses all new inpatient admissions for identification of status and medical necessity for admission; communicates clinical review process with appropriate Payors.
2. 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.
3. Coordinates with other members of the healthcare team to help identify and control inappropriate resource utilization.
4. Conducts concurrent admission and continued stay reviews based on appropriate utilization review criteria.
5. 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.
6. Follows up on denials communicated to the department and works with the revenue cycle staff to assist with appeals.
7. 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.
8. 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
Licensure(s): Registered Nurse License

Salary Information
Pay is dependent on applicant's relevant experience.

Salary Range: $37.82 to $56.73/hour

Benefits Information
Here, you matter. 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 time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career.

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.