Senior Nursing Utilization Specialist

Jackalope Digital LLC; Chicago, Northern (IL, KY); Hybrid; USD 90,000 - 120,000; Full time

Benefits offered by this job

Tuition reimbursement

Loan forgiveness

401(k) matching

Lifecycle benefits

Job summary

Northwestern Medicine seeks a Quality Utilization Specialist to apply medical necessity screening, review admissions, and coordinate with clinicians and payors to ensure appropriate and efficient hospital care. The role emphasizes improving utilization practices while maintaining patient-focused service in a dynamic hospital environment.

The QUS will collaborate across care teams, participate in performance improvement, and educate staff on best practices, contributing to high-quality care and

Qualifications

• Licensed Registered Nurse in 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.
• Analytical skills to analyze data and resolve problems.
• Computer skills including word processing and spreadsheets.

Responsibilities

• Applies medical necessity screening criteria and level of care guidelines to ensure appropriate admissions and length of stay.
• Completes initial admission and continuing stay reviews for hospitalized patients.
• Facilitates utilization review concurrent with hospitalization decisions and coordinates with care teams.
• Collaborates with Payor Specialists and third-party payors to communicate clinical information.
• Acts as a liaison with the clinical care team ensuring compliance with contracts and payor guidelines.
• Partners with leadership to identify and implement utilization processes for right care at the right time.
• Monitors data elements related to Utilization through reporting tools.
• Resolves utilization dilemmas and escalates when needed to Medical Directors or Lead Specialists.
• Makes referrals to physician advisors and review companies as appropriate.
• May participate in discharge planning rounds to ensure accurate medical necessity and payor communication.
• Interfaces with patients to provide education on level of care.
• Participates in Clinical Performance Improvement Initiatives related to documentation and utilization.
• Develops and presents education programs; uses dashboards for updates to physicians and teams.
• Promotes resolution of barriers to utilization and improves systems for optimal practice.
• May assist in reporting financial indicators like length of stay and denials.

Skills

Nursing

Leadership

Analytical skills

Communication

Education

Bachelor's degree in Nursing

Tools

Word processing

Spreadsheets

Job description

Northwestern Medicine seeks a Quality Utilization Specialist to apply medical necessity screening, review admissions, and coordinate with clinicians and payors to ensure appropriate and efficient hospital care. The role emphasizes improving utilization practices while maintaining patient-focused service in a dynamic hospital environment.

The QUS will collaborate across care teams, participate in performance improvement, and educate staff on best practices, contributing to high-quality care and