Utilization Review Case Manager RN-Emergency Department Full Time Days

The Emergency Department (ED) Utilization Review (UR) Case Manager RN reflects the mission vision and values of NM adheres to the organizations Code of Ethics and Corporate Compliance Program and complies with all relevant policies procedures guidelines and all other regulatory and accreditation standards

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.

Qualifications :

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

Additional Information :

Northwestern Medicine is an equal opportunity employer (disability VETS) and does not discriminate in hiring or employment on the basis of age sex race color religion national origin gender identity veteran status disability sexual orientation or any other protected status.

Background Check

Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and at times internal transfers. If you are offered a position with us you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check.  Results are evaluated on a case-by-case basis and we follow all local state and federal laws including the Illinois Health Care Worker Background Check Act.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position however all employment decisions will be made by a person. 

Benefits

We offer a wide range of benefits that provide employees with tools and resources to improve their physical emotional and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.

Sign-on Bonus Eligibility: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family. 

Remote Work :

No

Employment Type :

Full-time