Utilization Review RN

Children's Hospital Colorado; Aurora (CO); Hybrid; USD 84,558 - 126,838; Part time

Job summary

Children's Hospital Colorado in Aurora, CO, is seeking an Utilization Review RN to support medical necessity reviews and denial mitigation as part of a multidisciplinary team. The role is primarily remote with potential onsite shifts, and requires BSN, 3 years UR experience, and BLS/CPR certification.

The position is part time (24 hours/week) within Utilization Management, with weekend evenings and relocation assistance if needed.

Qualifications

• BSN degree required.
• Three years of recent UR experience in hospital or with a payor.
• BLS/CPR certification with at least 6 months before expiration.

Responsibilities

• Assesses all new inpatient admissions for status and medical necessity and communicates with payors.
• Assesses continuity of care with Case Managers regarding ongoing medical necessity and discharge plans.
• Coordinates with the healthcare team to identify and control inappropriate resource utilization.
• Conducts concurrent admission and continued stay reviews based on UR criteria.
• Uses information from Patient Access to follow up on authorizations with payors.
• Follows up on denials and assists with appeals with Revenue Cycle.
• Maintains clinical knowledge to help physicians document severity of illness and intensity of service for acute hospitalization criteria.
• Complies with CMS and Joint Commission Standards.

Skills

UR experience

Clinical nursing

Education

BSN

RN License

Job description

Location: Aurora

Position Type: Regular

Regular/Temporary: Regular

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: part time, 24 hours per week, eligible for benefits
Shift: weekend evenings - Saturday, Sunday, Monday 1500 - 2300

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.

This position is eligible for relocation assistance, if relocating from 100 miles or greater.

Duties & Responsibilities

• 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
• 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.

Annual Salary Range (Based on 40 hours worked per week): $84,558.69 to $126,838.03

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.

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Estimated Close Date: 08/31/2026