Registered Nurse Utilization Review 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 Management Job Status : flex, not eligible for benefits Shift : variable – must have availability to work at least 24 hours per 2‑week pay period. Shifts may include dayshift, evening shift, and weekend shifts, depending on unit staffing needs. Location : Primarily remote, occasional onsite at Children’s Hospital Colorado locations. Must live in Colorado or be willing to relocate. Duties & Responsibilities 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 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, documenting 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 nursing experience in a pediatric setting or three years of case management experience, including recent UR experience in a hospital or with a third‑party payor. Certification(s): BLS/CPR from the American Heart Association with at least six (6) months left before expiration required upon hire. Licensure: Current Colorado Registered Nurse (RN) license or RN license multistate compact. Salary Information 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 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. 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 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. The position is expected to stay open until the posted close date and will close upon a sufficient pool of qualified applicants being obtained. #J-18808-Ljbffr Children’s Colorado