Nurse Utilization & Care Optimization Specialist

Northwestern Medicine; Chicago (IL); On-site; USD 90,000 - 120,000; Full time

Job summary

Northwestern Medicine is seeking a senior Quality Utilization Specialist with Illinois RN licensure to lead clinical utilization reviews, ensure appropriate admissions and length of stay, and collaborate with payors to optimize patient care and cost efficiency.

The role requires strong leadership, analytical skills, and deep knowledge of hospital utilization processes, with involvement in performance improvement and interdisciplinary education.

Qualifications

• Licensed Registered Nurse in the state of Illinois (IDFPR).
• Bachelor's Degree in Nursing.
• 5 years of experience in acute inpatient hospital care.
• Proven leadership and diplomacy skills to affect positive outcomes.
• Organizational, team building, coaching, and conflict management to maximize the achievement of utilization outcomes.
• Analytical skills to independently collect, analyze, and interpret data, resolve problems requiring innovative solutions.
• Computer skills including word processing and spreadsheets.

Responsibilities

• Applies medical necessity screening criteria, level of care guidelines, and professional nursing knowledge to ensure that admissions & length of stay are appropriate.
• Completes initial admission and thereafter continuing stay reviews for all hospitalized patients.
• Facilitates utilization review concurrent with decisions on hospitalization and may perform duties in the ED, pre and post-operative, labor and delivery, external transfer, bed assignment, and/or other access points for hospitalization.
• Collaborates with Payor Specialists and third-party payors to communicate all relevant clinical information based on indicators and plan of care.
• Acts as a liaison with the clinical care team ensuring compliance with managed care contracts and payor guidelines while maintaining quality of care.
• Partners with leadership to identify, develop and implement utilization processes for right care at the right time.
• Monitors data elements related to Utilization through data reporting tools.
• Resolves utilization dilemmas and uses escalation pathways to secure information.
• Makes referrals to internal physician advisors and contracted review company per guidelines.
• Participates in discharge planning rounds to align documentation and orders with medical necessity.
• Interfaces with patients to provide education on level of care.
• Participates in Clinical Performance Improvement Initiatives relevant to Clinical Documentation and Utilization.
• Develops and presents service-line education; uses metrics and dashboards for updates to physicians and team.
• Collaborates to resolve barriers to utilization and improve systems.

Skills

Nurse leadership

Clinical documentation

Data analysis

Communication

Organizational skills

Problem solving

Computer skills

Education

Bachelor's degree in Nursing

Tools

Word processing

Spreadsheets (Excel)

Job description

Northwestern Medicine is seeking a senior Quality Utilization Specialist with Illinois RN licensure to lead clinical utilization reviews, ensure appropriate admissions and length of stay, and collaborate with payors to optimize patient care and cost efficiency.

The role requires strong leadership, analytical skills, and deep knowledge of hospital utilization processes, with involvement in performance improvement and interdisciplinary education.