Job Description
The Emergency Department (ED) Utilization Review (UR) Case Manager RN 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:
- Utilizes advanced clinical skills to perform utilization review on patients admitted through the Emergency Department.
- Maintains current knowledge of clinical criteria sets and evidence-based 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 up-to-date 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.
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 case-by-case basis and follow all state and federal guidelines.
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