Utilization Review RN
4 days ago
Days -Days 8:00 -4:30pm Registry
At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. This patient-first approach is what sets us apart as a leader in the healthcare industry. As an integral part of our team, you'll have the opportunity to join our quest for better healthcare, no matter where you work within the Northwestern Medicine system. At Northwestern Medicine, we pride ourselves on providing competitive benefits: from tuition reimbursement and loan forgiveness to 401(k) matching and lifecycle benefits, we take care of our employees. Ready to join our quest for better?
Job Description
Days -Days 8:00 -4:30pm Registry
The Utilization Review RN - IHR reflects the mission, vision, and values of NM, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
The Utilization Management RN (UM RN), functions as the primary liaison to the payer and all other related parties to ensure appropriate level of care through comprehensive concurrent review for medical necessity of outpatient, observation and inpatient stays. This role is responsible for assigned areas and assisting co-workers as needed. This position supports collaborative professional practice with all members of the care team. This position champions placement of the patient in the right status with appropriate and efficient resource utilization.
Responsibilities:
- Reviews admissions and continued stay patient charts, determining the necessity and appropriateness of hospitalization and care plans, using approved criteria.
- Maintains appropriate charting and reviews medical records for documentation completeness.
- Communicates with physicians to obtain orders for both hospital and post-hospital care or additional documentation when screening criteria is not met for inpatient treatment.
- Collaborates with attending physician to define appropriate level of care and service that best meet the patients' needs.
- This position works closely with all areas of the Care Coordination Team to ensure responsible use of resources related to patient care and appropriate length of stay. Maintains a working knowledge of the case management and discharge process and it's relation to the overall process of patient care.
- Maintains appropriate documentation to include specific utilization review activities.
- Refers cases not meeting criteria to the In House Physician Reviewer or Contracted Reviewer for collaborative determination of appropriate status.
- Communicates appropriate review information to HMO's, PPO's, and other third party payers to certify patients for their hospital stay and services rendered.
- Monitors indicators such as length of stay, observation rates, delays in services, resource utilization, quality and satisfaction outcomes for individual stays and patient populations.
- Works collaboratively with patient health care team to identify opportunities for improvement and implement best practice solutions.
- Collaborates with Patient Flow Supervisors to ensure all direct admissions and post-surgical admissions are assigned the appropriate patient type consistent with medical necessity.
- Stays up to date on industry best practices and maintains a network of professionals to exchange ideas and benchmark best practices.
- This position performs other duties as assigned.
- Resolves problems in a professional and timely manner by not blaming others, taking responsibility, focusing on solving the problem, enlisting the help of others, anticipate problems before they occur, and communicate solutions to those that need to know.
- Actively contributes to team goals by encouraging and helping each other perform to the best of their capabilities, developing and reaching goals together, and recognizing the contribution of others and promoting positive working relationships.
- Adapts to change, accepts new assignments, and improves ways of doing things with grace and enthusiasm. Looks for chances to learn new skills and helps others learn new tasks and accepts changes in the way we work. Tries to anticipate and handle changing priorities and schedules, while still managing to get our work completed as assigned.
- Identification of population served by this position:
- This position requires knowledge of the principles of growth and development over the life span, and the ability to assess data reflective of the patient's status.
- Includes being able to interpret the appropriate information needed to identify each patient's requirements relative to the patient's age-specific needs.
Required:
- Registered Nurse in the state of Illinois
- CPR certification
- 2-3 years clinical nursing experience.
- Bachelor of Science in Nursing
- Two to five years position related experience
- Certification by the American Case Management Association or the Commission for Case Management Certification
- Utilization Management certification
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.
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