1. Monitors for appropriateness of admission, continued stay, and readiness for discharge based on medical necessity as evidenced by appropriate documentation.
2. Demonstrates medical necessity using InterQual criteria. 
3. Maintains continuous and effective communication with Providers to ensure complete documentation reflecting medical necessity to support appropriate patient status orders and compliance with CMS regulations as related to utilization management.
4. Collaborates with third party payers by providing timely clinical documentation and seeking authorization as needed in partnership with Insurance Verification.
5. Facilitates appeals based on documented medical necessity in partnership with attending Providers. Collaborates with denials management team to navigate appeals process.
6. Participates in internal auditing, data tracking and reporting through the Utilization Review Committee to ensure best practice.
7. Supports the needs of the Case Management department and the organization within scope of practice, as needed.
8. Role models the principals of a Just Culture and Organizational Values.
9. Must be HIPAA compliant.

• One-year recent experience in acute care hospital Utilization Review or equivalent, required. 

• Licensed as a Registered Nurse in the state of Colorado or from a valid compact state, required

• N/A

• Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.

• Associate?s or Bachelor's degree in nursing, required.

Benefits at Vail Health (Full Time) Include:

• Competitive Wages & Family Benefits:
  • Competitive wages
  • Parental leave (4 weeks paid)
  • Housing programs
  • Childcare reimbursement 
• Comprehensive Health Benefits: 
  • Medical
  • Dental 
  • Vision
• Educational Programs: 
  • Tuition Assistance 
  • Existing Student Loan Repayment
  • Specialty Certification Reimbursement
  • Annual Supplemental Educational Funds
• Paid Time Off:
  • Up to five weeks in your first year of employment and continues to grow each year.
• Retirement & Supplemental Insurance:
  • 403(b) Retirement plan with immediate matching 
  • Life insurance
  • Short and long-term disability
• Recreation Benefits, Wellness & More:
  • Up to $1,000 annual wellbeing reimbursement
  • Recreation discounts
  • Pet insurance

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About Vail Health

Vail Health, formerly Vail Valley Medical Center, is a nonprofit community health care system serving patients and guests from around the world. Locally operated and governed by a volunteer board of directors, Vail Health includes a 56-bed hospital, accredited by the Joint Commission. Our 24/7 emergency department in Vail is a Level III Trauma Center with a nearby helipad for necessary medical transports. Vail Health provides a wide array of services and access points including Beaver Creek Medical Center, urgent care clinics in Avon and Gypsum, our Edwards medical campus, Eagle Healthcare Center and a multispecialty clinic in Frisco. Howard Head Sports Medicine offers physical therapy services at 10 locations and works closely with our internationally renowned orthopaedic partners at The Steadman Clinic and Vail-Summit Orthopaedics. In addition, Vail Health's Shaw Cancer Center and Sonnenalp Breast Center are the region’s only fully accredited cancer treatment center and comprehensive breast center. The Vail Clinic, which was founded in 1965, officially became “Vail Valley Medical Center” in 1980, its first year as a full-service hospital. At that time, we had one primary locatio...n and 25 physicians. Today, Vail Health has locations in nine towns, nearly 1,000 employees, 260 physician partners and 85 volunteers. Vail Health is an equal-opportunity employer. The hospital is handicap accessible and adheres to the Americans with Disabilities Act. Smoking is prohibited in our facilities. This includes e-cigarettes.

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