Quality Utilization Nurse Specialist

Northwestern Memorial Hospital; Chicago (IL); On-site; USD 55,000 - 90,000; Full time

Benefits offered by this job

Tuition reimbursement

Student loan repayment

Professional development

Wellbeing fund

401(k) matching

Medical, dental and vision coverage

Life insurance

Annual incentive bonus

Paid time off and holidays

Job summary

Northwestern Memorial Hospital is seeking a Quality Utilization Specialist (RN) to lead utilization reviews and ensure appropriate admissions and length of stay across hospital teams.

The role collaborates with clinicians and payors, drives performance improvement initiatives, and supports education on utilization best practices within a complex health system. Strong leadership and analytical skills are essential.

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 utilization outcomes.
• Analytical skills necessary to independently collect, analyze, and interpret data, resolve problems.
• 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 Emergency Department, 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 effectively communicate clinical information based on indicators and plan of care.
• Acts as a liaison with the clinical care team assuring compliance with managed care contracts and payor guidelines while maintaining quality of care.
• Partners with operational and medical leadership to identify, develop and implement utilization processes.
• Monitors data elements inherently related to Utilization through data reporting tools.
• Effectively resolves utilization dilemmas and uses escalation pathways to secure further information.
• Makes appropriate referrals to internal physician advisors and contracted third party review company.
• May participate in interdisciplinary discharge planning rounds to facilitate communication on documentation and orders for medical necessity.
• Interfaces with patients to provide education on level of care.
• Participates in Clinical Performance Improvement Initiatives related to Clinical Documentation and Quality Utilization.
• Develops, coordinates, presents, and participates in service-line and clinician education programs.

Skills

Registered Nurse

Utilization review

Leadership

Analytical skills

Computer skills

Education

Bachelor's Degree in Nursing

Tools

EMR systems

Job description

Northwestern Memorial Hospital is seeking a Quality Utilization Specialist (RN) to lead utilization reviews and ensure appropriate admissions and length of stay across hospital teams.

The role collaborates with clinicians and payors, drives performance improvement initiatives, and supports education on utilization best practices within a complex health system. Strong leadership and analytical skills are essential.