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.

Utilization Management

Flex, not eligible for benefits

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.

This position will be primarily remote but may require onsite work at one of the Children’s Hospital Colorado locations. All team members must live in Colorado or be willing to relocate before starting.

• 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 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.

• Bachelor of Science in Nursing (BSN).
• Three years of nursing experience in a pediatric setting or three years of case‑management experience with recent utilization review experience in a hospital or with a third‑party payor.
• BLS/CPR from the American Heart Association with at least six (6) months remaining before expiration, required upon hire.
• Current Colorado Registered Nurse (RN) license or multistate RN license compact.

Hourly rate: $50.68.

As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package, including base pay, incentives, paid sick leave, a robust wellness program, an annual employee bonus program, and annual base pay increases based on performance.

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.