Clinical Utilization Review Nurse

2 days ago

Lake Forest, California, United States Northwestern Memorial Healthcare Full time
Job Summary

We are seeking a highly skilled Clinical Utilization Review Nurse to join our team at Northwestern Memorial Healthcare. As a key member of our healthcare team, you will play a critical role in ensuring the efficient and effective delivery of patient care.

Responsibilities
  • Determine the most appropriate level of care and admission status for patients, applying approved criteria and guidelines in decision making.
  • Collaborate with attending physicians to ensure accurate hospital status orders.
  • Assign patients to the appropriate units based on clinical assessment, balancing resource utilization and operational processes.
  • Coordinate with unit charge nurses for bed placement and collaborate with nursing operations leaders for throughput issues.
  • Respond to and assign bed requests and transfer orders in the electronic medical record.
  • Document unusual occurrences and patient relations issues, making referrals to risk management, infection control, and quality departments as needed.
  • Evaluate and analyze quality/utilization cases, admission/discharge criteria, observation/1-day stays, readmits in 30 days, Medicare, and diagnosis-related criteria.
  • Consult with physicians on admission level of care status and stay up-to-date on Medicare rules and regulations.
  • Perform medical record reviews to assess appropriateness of admissions and work with the Emergency Room and attending physicians to divert unnecessary admissions.
  • Monitor and document avoidable days and recommend changes in services or processes.
  • Respond to requests from denials management RNs for appeal assistance and utilize downtown procedures for bed placement when applicable.
  • Assist with data collection and reporting for throughput and bed placement, and perform chart audits as requested by manager/director.
Qualifications
  • Registered Nursing license issued by the State of Illinois.
  • Bachelor's of Science in Nursing.
  • At least two to five years of patient care experience in a hospital setting.
  • Able to multitask quickly and process multifactorial stimulation accurately.
  • Critical thinking skills, decisive judgment, and the ability to work with minimal supervision.
  • Past experience in admissions, utilization review activities, discharge planning, and/or case management.
Preferred Qualifications
  • Utilization Review experience.
  • Masters of Science in Nursing.
  • Membership in Professional Nursing Organization.
  • Certification in Case Management (ACM).

We are an affirmative action/equal opportunity employer and do 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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