Northwestern Medicine · 3 weeks ago
RN Utilization Specialist-Utilization Review Casual Days
Palos Heights, IL
Part-time
Onsite
Mid Level
3+ years expNorthwestern Medicine is a leader in the healthcare industry, dedicated to providing patient-first care. The RN Utilization Specialist plays a critical role in ensuring appropriate patient care and cost-effective healthcare services through collaboration with clinical teams and utilization review processes.
Emergency MedicineHealth CareHospitalMedicalNutritionRehabilitation
Responsibilities
Applies medical necessity screening criteria, level of care guidelines, and professional nursing knowledge to ensure that admissions & length of stay are appropriate
Completes initial admission and thereafter continuing stay reviews for all hospitalized patients
Facilitates utilization review concurrent with decisions on hospitalization and may perform duties in the Emergency Department, pre- and post-operative, labor and delivery, external transfer, bed assignment, and / or other access points for hospitalization
Collaborates with the Payor Specialists and third-party payors to effectively communicate all relevant clinical information based on clinical indicators and the plan of care
Acts as a liaison with the clinical care team assuring compliance with managed care contracts and payor guidelines while maintaining quality of care
Partners with operational and medical leadership to identify, develop and implement utilization processes that foster the right care at the right time in the right setting
Monitors data elements inherently related to Utilization through data reporting tools
Effectively resolves utilization dilemmas and as needed uses available escalation pathways (Utilization Medical Director (s) or the Lead Utilization Specialists) to secure further information or expertise to resolve identified issues
Makes appropriate referrals to internal physician advisors and contracted third party review company per Department guidelines
May participate in interdisciplinary discharge planning rounds to facilitate communication with the care team on documentation and orders necessary to assign accurate medical necessity, level of care, and communication with the payor
Interfaces with patients as appropriate to provide education on level of care
Increases stakeholder understanding of best practices in utilization and internal performance against benchmarks, through a variety of educational forums
Develops, coordinates, presents, and participates in service-line and clinician education programs
Utilizes standardized reports (metrics/dashboard) and provides updates for physicians and the interdisciplinary team members on a regular basis
Collaborates with the interdisciplinary team to promote the resolution of barriers related to utilization of services and institute changes that improve systems and promote optimal utilization practices
May assist in the reporting of financial indicators including length of stay, resource utilization, denials and appeals
Participates in the development, implementation, evaluation and revision of quality utilization tools in collaboration with the healthcare team
Assists in Recovery Audit Contractor (RAC) and other audit follow up and contributes to appeals on insurance denials as requested
Maintains current knowledge of federal and state laws and regulations related to utilization
Actively participates on departmental and hospital committees and taskforces as assigned
Complies with Northwestern Medicine policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct
Facilitates review of high risk cases by the Office of General Counsel, Corporate Compliance and Integrity, Risk Management and informs appropriate members of the healthcare team as to interventions. Coordinates interventions in collaboration with the healthcare team
Participates in hospital and department quality improvement initiatives
Qualification
Required
Licensed Registered Nurse in the state of Illinois (IDFPR)
Three years of experience in acute inpatient hospital care
Organizational, team building, coaching, and conflict management to maximize the achievement of utilization outcomes
Analytical skills necessary to independently collect, analyze, and interpret data, resolve problems requiring innovative solutions
Computer skills including word processing and spreadsheets
Preferred
Bachelor's Degree in Nursing
Benefits
Tuition reimbursement
Loan forgiveness
401(k) matching
Lifecycle benefits
Company
Northwestern Medicine
Northwestern Medicine is the collaboration between Northwestern Memorial HealthCare and Northwestern University Feinberg School of Medicine around a strategic vision to transform the future of health care.
10001+ employees
H1B Sponsorship
Northwestern Medicine has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (75)
2024 (66)
2023 (70)
2022 (78)
2021 (35)
2020 (39)
Funding
Current Stage
Late StageTotal Funding
$25M2018-06-26Grant· $25M
Leadership Team
Howard Chrisman, MD
President and CEO
John A. Orsini, CPA
Senior Vice President and Chief Financial Officer
Recent News
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