Utilization Review RN: Improve Care & Payer Collaboration

Advocate Health Care; Oak Brook (IL); On-site; USD 85,000 - 110,000; Full time

Job summary

Advocate Health Care seeks a Registered Nurse with utilization management experience to join our UM team in Oak Brook, IL. You will document reviews, collaborate with care teams, and ensure regulatory compliance to support timely patient care.

Responsibilities include educating staff on admission status, maintaining payer relationships, and applying UM criteria; this role requires an active RN license and a minimum of 3 years in clinical or UM roles.

Qualifications

• Registered Nurse license issued by the state.
• Bachelor’s Degree (or equivalent knowledge) in Nursing.
• Typically requires 3 years of experience in clinical nursing, utilization and/or quality management.

Responsibilities

• Documents utilization review activity per department and medical center standards in a timely manner. Performs and documents accurate and timely concurrent and retrospective reviews based on approved established criteria.
• Communicates effectively with the healthcare team. Works closely with medical staff, hospital departments and ancillary services as part of Outcome Facilitation Team/Multidisciplinary Team in expediting care delivery to avoid delays in timely service provision and implementing and reporting utilization management (UM) activities, as applicable.
• Collaborates with managers, physicians, medical directors, advisory groups and treatment teams for issues related to physician practices and best practices for the patient’s plan of care. Refers cases to physician advisor as needed to ensure accurate status and compliance with regulatory guidelines.
• Remains knowledgeable in issues of healthcare regulations, reimbursement issues, impact on length of stay and community resources. Provides clinical updates to payers and/or external review organizations, collects data, coordinates denial activity, supports UM activity, and manages avoidable delays.
• Develops and maintains productive relationships with community-based agencies and networks by representing Aurora Health Care in a positive manner working collaboratively, internally and externally, to meet patient/family needs.
• Serves as an educator and expert resource to medical and hospital staff regarding admission status and acute care criteria, utilization management issues, and relevant regulatory requirements.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Skills

Microsoft Office

Analytical thinking

Interpersonal communication

Conflict resolution

Team collaboration

Critical thinking

Education

Bachelor’s Degree in Nursing

Tools

Microsoft Office Suite

Job description

Advocate Health Care seeks a Registered Nurse with utilization management experience to join our UM team in Oak Brook, IL. You will document reviews, collaborate with care teams, and ensure regulatory compliance to support timely patient care.

Responsibilities include educating staff on admission status, maintaining payer relationships, and applying UM criteria; this role requires an active RN license and a minimum of 3 years in clinical or UM roles.