Supervisor, Nursing Utilization Review

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Department

• Team Leadership & Performance Management
  Directly supervise RN utilization management staff; manage schedules, assignments, and productivity during Workday. Conducts daily rounds, monitors work queues and assignments with staff daily to ensure appropriate coverage.
  Monitors staff workload, reviews productivity, conducts quality reviews/audits.
  Supports the execution of team performance goals in support of organizational initiatives and in collaboration with the Director of Revenue Integrity.
  Promotes team and individual process improvements with coaching, case studies, and team meetings.
  Track performance and quality measures using dashboards and reports. Analyzes monthly Utilization Management data for best practice and process improvement.
  Develops and delivers education to the team to strengthen performance and knowledge for continuous team development. Support onboarding and all continuous learning needs for the team.
  Participates in the hiring, orienting, training, performance reviews, counseling, disciplining and terminating of employees.
  (30%)
• Clinical & Operational Oversight
  Monitors and evaluates Utilization Management, work in partnership with UM Physicians, staff and applicable key stakeholders to reduce inappropriate overutilization of services.
  Leads the team as a subject matter expert with the ability to answer clinical questions related to utilization review and provide support on case reviews. Maintain expertise through ongoing case review as necessary.
  Participates in the clinical denial and appeal process, in partnership with the Revenue Integrity and Billing teams. Review denials reason codes and draft appeal letters with a consolidation of clinical information to advocate for the appropriate status of the patient and resources utilized.
  Reviews complex utilization cases and guide the team in applying the appropriate medical necessity criteria and/or payer policies to determine necessary actions.
  Escalates findings and engage the necessary leadership to address issues in a timely and productive manner.
  (30%)
• Compliance & Regulatory Monitoring
  Provides daily staff oversight and direction on Utilization Management processes to ensure compliance with all governmental and accredited agencies. Monitor compliance with all utilization management regulatory requirements. Ensure adherence to regulatory turnaround times for Utilization Management decisions.
  Participates in the development, refinement, implementation, and administration of Utilization Management programs, policies, procedures, and standard work. Maintains compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines. Support and guide staff to meet compliance benchmarks and timely documentation.
  Protects Patient Rights as they pertain to the ethical and legal issues of confidentiality during the case management and utilization management process.
  Helps prepare for and assists with internal audits and all external regulatory and compliance reviews (e.g., CMS, URAC, NCQA).
  (15%)
• Collaboration & Communication
  Responsible for effective collaboration with internal and external resources to achieve goals and objectives.
  Leads productive meetings with interdisciplinary team members (physicians, residents, mid-levels, nursing, other healthcare professionals and external providers, etc.)- Develops and initiates cost saving strategies to achieve decreases in resource utilization and patient throughput- Participates on committees and workgroups to develop collaborative and integrated work processes
  Serves as liaison with Physician Advisors, Case Management, Clinical Documentation Integrity, Revenue Integrity, Patient Access, Compliance, Billing, Contracting, and Providers.
  Assists in the development of department policies, procedures, and training materials.
  Resolves escalated member/provider concerns and fosters a team-based problem-solving approach.
  (25%)

• Associate's Degree in Nursing Required

• 1-3 years clinical nursing experience Required and
• 1-3 years utilization management experience Required and
• 1-3 years supervisory or management experience Required

• RN-Registered Nurse - DORA - Department of Regulatory Agencies Required

• Knowledge of the regulatory environment that governs
• Critical Thinking - Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Active Listening - Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Judgment and Decision Making - Considering the relative costs and benefits of potential actions to choose the most appropriate one.
• Service Orientation - Actively looking for ways to help people. Effectively collaborate with and respond to varied personalities in differing emotional conditions and maintain professional composure at all times. Strong customer service orientation and aptitude.
• Communication Skills- Ability to communicate clearly and effectively, both in writing and verbally to providers, patients, and team members.
• Data Analysis - Extensive use of quantitative and qualitative research and statistical methods for analyzing data.
• Research - ability to leverage resources to acquire needed information
• Demonstrated proficiency at the intermediate (preferably advanced) level of Microsoft Excel
• Demonstrated proficiency in the Microsoft Office Suite of products (i.e. Word, and PowerPoint)

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver's 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado's primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.