Job Description

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 evidencebased 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 uptodate 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.

#INDNW

#LICC1 

Qualifications :

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 affirmative action/equal opportunity employer 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.

If we offer you a job we will perform a background check that includes a review of any criminal convictions. A conviction does not disqualify you from employment at Northwestern Medicine. We consider this on a casebycase basis and follow all state and federal guidelines.

Remote Work :

No

Employment Type :

Fulltime

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