RN Utilization Specialist: Optimize Care & Coverage

Northwestern Medicine; Palos Heights (IL); On-site; USD 54,000 - 85,000; Full time

Benefits offered by this job

Tuition Reimbursement

Student Loan Repayment

Professional Development

Wellbeing Fund

Matching 401(k)

Medical, Dental, Vision coverage

Life insurance

Annual salary increase and incentive

Paid time off and holidays

Job summary

Northwestern Medicine is seeking an RN Utilization Specialist in Illinois to apply medical necessity criteria, determine appropriate level of care, and collaborate with clinicians to ensure efficient hospital utilization.

The role emphasizes performance improvement, data monitoring, and coordinating with payors; requires IL RN license and 3 years acute inpatient experience; a BSN is preferred. We offer a comprehensive benefits package and professional development.

Qualifications

• Licensed Registered Nurse in the state of Illinois (IDFPR).
• Three years of experience in acute inpatient hospital care.
• Bachelor’s Degree in Nursing preferred.

Responsibilities

• Applies medical necessity screening criteria, level of care guidelines, and nursing knowledge to ensure admissions & length of stay are appropriate.
• Completes initial admission and continuing stay reviews for all hospitalized patients.
• Facilitates utilization review concurrent with decisions on hospitalization.
• Collaborates with Payor Specialists and third party payors to communicate clinical information.
• Acts as a liaison with the clinical care team to ensure compliance with contracts and payor guidelines.
• Partners with leadership to identify and implement utilization processes.
• Monitors data elements related to Utilization through reporting tools.
• Resolves utilization dilemmas and uses escalation pathways as needed.
• May participate in discharge planning rounds and educate patients on level of care.
• Develops and presents service-line and clinician education programs.

Skills

Registered Nurse

Analytical skills

Communication skills

Team collaboration

Hospital environment

Education

Bachelor's Degree in Nursing

Illinois RN License

Tools

Word processing

Excel

Job description

Northwestern Medicine is seeking an RN Utilization Specialist in Illinois to apply medical necessity criteria, determine appropriate level of care, and collaborate with clinicians to ensure efficient hospital utilization.

The role emphasizes performance improvement, data monitoring, and coordinating with payors; requires IL RN license and 3 years acute inpatient experience; a BSN is preferred. We offer a comprehensive benefits package and professional development.