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RN Utilization Review

Denver, CO, United States


SHIFT: No Weekends

SCHEDULE: Full-time

The Utilization Review RN provides clinical information to insurance companies according to the terms of the contract, receive/seek out authorization/certification for the hospital stay, perform concurrent denials, determine the correct patient status by reviewing medical necessity and communicate this to the facilities, follow the X-code process per HCA policy and maintain communication with the facility case managers.  


This position will focus on initial and continued stay utilization review and denials to include assessment of medical records for appropriateness as well as level of care provided.  A team approach with the facility Case Management department is essential.

  • Perform InterQual review within one business day on all inpatient admissions. (Excluding FC 1, 2, 15, 99 (Medicare, self-pay, uninsured/charity) & Mother/Well-Baby). 
  • Document note to support inpatient admission.
  • Review for inpatient admission status order.
  • Ensure the patient’s status is correct in Meditech & MIDAS.
  • Perform continued stay reviews via InterQual application, at a minimum of every 3 days.
  • Review concurrent denials and work with the facility and physician to overturn.
  • Communicate the denial status to the facility and physician.
  • Follow all HCA standards regarding documentation and education.
  • Communicate with physicians regarding patient status.
  • Communicate medical necessity and responder criteria to the facility case managers.
  • Review the Authorization/Certification report daily to determine deficiencies. 
  • Documentation to take place in Midas within the Care Enhancement Review Entry (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable/Denied Days Module.

HealthONE® is the largest healthcare system in the metro Denver area with more than 10,000 employees. As part of the HealthONE family, The Medical Center of Aurora, North Suburban Medical Center, Presbyterian/St. Luke’s Medical Center, Rocky Mountain Hospital for Children, Rose Medical Center, Sky Ridge Medical Center, Swedish Medical Center, and Spalding Rehabilitation Hospital work together to provide a higher level of care. In addition, our family of services includes seven free-standing emergency departments, numerous ambulatory surgery centers, CareNow Urgent Care Clinics & Occupational Medicine, physician practices, and AIRLIFE-DENVER, which provides critical care air and ground transportation across a 10-state region.


  • BSN, Bachelor of Science in Nursing (preferred)
  • Registered Nurse (RN)
  • InterQual (required)
  • Acute care hospital case management/utilization review experience
  • Third party payer experience (helpful)
  • Denials Management (helpful)

Facility: HealthOne
Job ID: 03174-78479
Category: Nursing - Professional
Contract: Full-time
Shift: No Weekends
Job Class: Regular

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