Quality Utilization Nurse Specialist

Northwestern Memorial Healthcare; Chicago (IL); On-site; USD 75,000 - 100,000; Full time

Job summary

Northwestern Medicine is seeking a seasoned Quality Utilization Specialist to support hospital utilization, enhance patient care decisions, and ensure medical necessity documentation across the system.

The role collaborates with clinicians, reviews admissions and stays, and drives performance improvement initiatives while ensuring compliance with policies and payer guidelines in a dynamic healthcare environment.

Responsibilities

• Applies medical necessity screening criteria, level of care guidelines, and professional nursing knowledge to ensure admissions and length of stay are appropriate.
• Completes initial admission and continuing stay reviews for hospitalized patients.
• Facilitates utilization review in the acute care setting and coordinates with clinical teams.
• Communicates with payors to relay relevant clinical information and plan of care.
• Acts as a liaison to ensure compliance with managed care contracts and payor guidelines.
• Partners with leadership to implement utilization processes and improve systems.
• Monitors data elements related to utilization and uses dashboards for updates.

Job description

Northwestern Medicine is seeking a seasoned Quality Utilization Specialist to support hospital utilization, enhance patient care decisions, and ensure medical necessity documentation across the system.

The role collaborates with clinicians, reviews admissions and stays, and drives performance improvement initiatives while ensuring compliance with policies and payer guidelines in a dynamic healthcare environment.