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Quality Utilization Specialist, Emergency Department, Full-time, Days
2 months ago
We are seeking a highly skilled Quality Utilization Specialist 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 highest quality patient care and optimal resource utilization in our Emergency Department.
Key Responsibilities- Apply medical necessity criteria, level of care guidelines, and professional nursing knowledge to ensure that the most appropriate hospital status order is recommended.
- Partner with medical staff within the hospital to ensure the most appropriate status order is placed with the information known at the time.
- Monitor the bed request order placed by the Emergency Department Residents and members of the medical staff and recommend changes as needed based on utilization review.
- Complete all admission reviews within the shift as prioritized by team leadership and complete follow-up review timely and appropriately as required.
- Effectively provide outreach to any third-party review company to ensure timely reviews and determinations of the patient's hospital status.
- Partner with hospital Patient Throughput staff, medical staff, and nursing leadership to coordinate bed placement that is appropriate with the patient's clinical condition and the patient's status order.
- Collaborate with the Payor Specialists, as needed, to effectively communicate all relevant information to the payor.
- Collaborate with the Social Work Team to communicate payor determinations and discuss the plan of care.
- Partner with operational and medical leadership in a given service line or team to identify, develop, and implement successful communication, education, and processes to engage physicians and promote optimal clinical utilization.
- Query medical staff as needed to ensure the appropriate level of care or hospital status is documented and assigned.
- Monitor the utilization of level of care designations, length of stay changes, avoidable days, and readmissions through data analysis and reporting.
- Review and enter electronically appropriate clinical information based on payor guidelines.
- Ensure thorough, accurate, and timely communication with the payor and communicate, among other data points, the patient's clinical indicators and plan of care.
- Escalate cases as appropriate to the Quality Utilization Medical Directors or Lead Quality Utilization Specialists.
- Participate in interdisciplinary discharge planning rounds, bed planning huddles as needed to facilitate communication with the clinician care team.
- Participate in denial prevention strategies as advised by Quality Utilization Leadership.
- Collect data related to status changes and bed/unit changes at each shift as well as barriers encountered during said shift. Implement surveillance and reporting to identify areas of concern and strength.
- Monitor internal and external trends to identify priorities.
- Set and achieve appropriate goals for quality, patient safety, and innovation.
- Teach/orient/train nurses to the role and others as needed.
- Remain flexible in assignment coverage which includes working in routine Quality Utilization operations and in the non-Emergency Department environment, as needed, and at the direction of the Quality Utilization Leadership Team.
- Remain competent in the following areas regardless of payor type: utilization review criteria, observation carve outs, and denials prevention strategies.
- Ensure that Event Management in EPIC is accurate on every line at the time of each review.
- Use data to drive decisions and plan, participate in, and implement performance improvement strategies related utilization review outcomes.
- Maintain high levels of staff engagement and performance.
- Participate in the development, implementation, evaluation, and revision of quality utilization tools in collaboration with healthcare team.
- Collaborate effectively across departments, including but not limited to directors and managers of quality/process improvement/analytics, chief medical officers, chief nursing executives, and operations executives.
- Actively participate on departmental and hospital committees and taskforces as assigned.
- Develop, coordinate, present, and participate in service-line and clinician education programs.
- Comply with Northwestern Memorial Hospital policies on patient confidentiality including HIPAA requirements and Personal Rules of Conduct.
- Registered Nurse in the State of Illinois.
- Bachelor's degree in nursing.
- 2 years in Quality Utilization Specialist position or related role.
- Mastery of utilization management and level of care guidelines.
- Proven leadership skills to affect positive Quality Utilization outcomes.
- Statistics, quantitative, and analytic skills relevant to the role.
- Analytical skills necessary to independently collect, analyze, and interpret data, resolve problems requiring innovative solutions, and to negotiate in sensitive situations.
- High level of energy and enthusiasm; flexible/adaptable ability to work with diverse group of healthcare professionals in a matrix environment.
- Effective problem-solving and multi-tasking, verbal and written communication skills.
- Basic computer skills including word processing and spreadsheets.
- 5+ years of relevant experience.
- Master's degree in Nursing.
