Quality Utilization Specialist, Emergency Department, Full-time, Rotating - Utilization Review
Company: Northwestern Memorial Hospital
Location: Chicago
Posted on: November 19, 2023
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Job Description:
Quality Utilization Specialist, Emergency Department, Full-time,
RotatingAt 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?
Benefits
* Annual Employee Incentive Bonus
* $6,000 Student Loan Repayment ($5,000 part-time)
* $5,250 Tuition Reimbursement per year ($3,000 part-time)
* $1,000 Professional Development per year ($500 part-time)
* $250 Wellbeing Fund per year
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?
Description
The Quality Utilization Specialist, ED 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.
Responsibilities:
* Applies medical necessity criteria, level of care guidelines, and
professional nursing knowledge to ensure that the most appropriate
hospital status order is recommended.
* Partners with medical staff within the hospital to ensure the
most appropriate status order is placed with the information known
at the time.
* Monitors the bed request order placed by the Emergency Department
Residents and members of the medical staff and recommends changes
as needed based on utilization review.
* Completes all admission reviews within the shift as prioritized
by team leadership and completes follow-up review timely and
appropriately as required.
* Effectively provides outreach to any third party review company
to ensure timely reviews and determinations of the patients
hospital status.
* Partners with hospital Patient Throughput staff, medical staff
and nursing leadership to coordinate bed placement that is
appropriate with the patients clinical condition and the patients
status order.
* Collaborates with the Payor Specialists, as needed, to
effectively communicate all relevant information to the payor.
* Collaborates with the Social Work Team to communicate payor
determinations and discuss the plan of care.
* Partners 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.
* Queries medical staff as needed to ensure the appropriate level
of care or hospital status is documented and assigned.
* Monitors the utilization of level of care designations, length of
stay changes, avoidable days and readmissions through data analysis
and reporting.
* Reviews and enters electronically appropriate clinical
information based on payor guidelines.
* Ensures thorough, accurate and timely communication with the
payor and communicates, among other data points, the patients
clinical indicators and plan of care.
* Escalates cases as appropriate to the Quality Utilization Medical
Directors or Lead Quality Utilization Specialists.
* Participates in interdisciplinary discharge planning rounds, bed
planning huddles as needed to facilitate communication with the
clinician care team.
* Participates in denial prevention strategies as advised by
Quality Utilization Leadership.
* Collects data related to status changes and bed/unit changes at
each shift as well as barriers encounters during said
shift.Implement surveillance and reporting to identify areas of
concern and strength.
* Monitors internal and external trends to identify priorities.
* Sets and achieves appropriate goals for quality, patient safety,
and innovation.
* Teaches/orients/trains nurses to the role and others as
needed.
* Remains 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.
* Remains competent in the following areas regardless of payor
type: utilization review criteria, observation carve outs, and
denials prevention strategies.
* Ensures that Event Management in EPIC is accurate on every line
at the time of each review.
* Uses 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.
* Participates in the development, implementation, evaluation and
revision of quality utilization tools in collaboration with
healthcare team.
* Collaborates 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 participates on departmental and hospital committees and
taskforces as assigned.
* Develops, coordinates, presents, and participates in service-line
and clinician education programs.
* Complies with Northwestern Memorial Hospital policies on patient
confidentiality including HIPAA requirements and Personal Rules of
Conduct.
Qualifications
Required:
* 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.
Preferred:
* 5+ years of relevant experience.
* Master's degree in Nursing.
Equal Opportunity
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.
Keywords: Northwestern Memorial Hospital, Chicago , Quality Utilization Specialist, Emergency Department, Full-time, Rotating - Utilization Review, Other , Chicago, Illinois
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