Northwestern Medicine · 13 hours ago
Utilization Review Case Manager RN-Emergency Department Full Time Days
Lake Forest, IL
Full-time
Onsite
Mid, Senior Level
3+ years expNorthwestern Medicine is a leader in the healthcare industry focused on patient-first interactions. The Emergency Department Utilization Review Case Manager RN will utilize advanced clinical skills to perform utilization reviews, promote effective resource utilization, and collaborate with healthcare providers to ensure optimal patient outcomes.
Emergency MedicineHealth CareHospitalMedicalNutritionRehabilitation
Responsibilities
Utilizes advanced clinical skills to perform utilization review on patients admitted through the Emergency Department
Maintains current knowledge of clinical criteria sets and evidence-based research around utilization review
Promotes and evaluates the effective utilization of resources using current clinical knowledge to achieve optimal clinical and resource outcomes
Performs Medical Necessity Outreach (MNO) with providers to clarify severity of illness and intensity of services offered
Build rapport with ED provider staff
Document the medical necessity for the observation status in the electronic medical record
Monitors electronic medical record track board for eligible patients
Places hospital status orders in collaboration with ED providers
Documents unusual occurrences and patient relations issues; makes appropriate referrals to risk management, infection control and quality departments
Collaborates with the ED Case Manager/Social Worker on patient specific discharge planning, safety, or clinical concerns of a patient that is being reviewed
Partners with manager/director in evaluating and analyzing quality/utilization cases, admission/discharge criteria, ED observation cases, and ED to Observation data
Consults with physicians in assigning admission level of care status and uses physician advisory group as needed
Stays up-to-date on Medicare rules and regulations for hospital
Performs medical record review to assess for appropriateness of admissions
Monitors and documents avoidable days and recommends change in services or processes
Develops and educates staff on clinical practice guidelines/Protocols/pathways that complement industry standards to reduce unnecessary admissions, ED length of stay and resource consumption while maintaining quality of care
Monitors documentation of an appropriate diagnosis for outpatient/observation testing to pass medical necessity. Educates ED physicians on documentation best practice
Qualification
Required
Registered Nursing license issued by the State of Illinois
Bachelor of Science in Nursing
3 or more years of related clinical or utilization review experience
Preferred
Master of Science in Nursing
Membership in Professional Nursing Organization
Certification in Case Management (ACM or CCM)
5 or more years of clinical or utilization review experience
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
2026-01-13
Near North Health
2025-12-01
Company data provided by crunchbase