RN Utilization Specialist: Drive Right-Care Decisions

Northwesternmedicine; Palos Heights (IL); On-site; USD 90,000 - 120,000; Full time

Job summary

Northwestern Medicine is seeking an RN Utilization Specialist to support hospital utilization through medical necessity reviews and collaboration with clinical teams. The role focuses on appropriate admission decisions, level of care determinations, and documentation aligned with patient plans.

The specialist will work with payor partners, drive utilization improvements, and contribute to performance metrics using data trends.

Qualifications

• Licensed registered nurse with hospital experience.
• Knowledge of utilization review concepts and processes.
• Familiarity with medical necessity criteria and level of care guidelines.

Responsibilities

• Applies medical necessity screening criteria to ensure appropriate admissions and LOS.
• Performs initial admission and continuing stay reviews for hospitalized patients.
• Collaborates with payor specialists to communicate clinical information for coverage decisions.
• Acts as liaison with care team to ensure compliance with contracts and guidelines.
• Participates in performance improvement initiatives and data-driven reviews.

Skills

RN license

Hospital utilization

Clinical workflows

Education

Bachelor of Science in Nursing

Tools

EMR systems

Job description

Northwestern Medicine is seeking an RN Utilization Specialist to support hospital utilization through medical necessity reviews and collaboration with clinical teams. The role focuses on appropriate admission decisions, level of care determinations, and documentation aligned with patient plans.

The specialist will work with payor partners, drive utilization improvements, and contribute to performance metrics using data trends.