Quality Utilization Specialist, Emergency Department, Full-time, Days

Job Description

The Quality Utilization Specialist, ED reflects the mission, vision, and values of NM, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, and all other regulatory and accreditation standards.

Responsibilities :

• Applies medical necessity criteria, level of care guidelines, and professional nursing knowledge to ensure that the most appropriate hospital status order is recommended.
• Partners with medical staff within the hospital to ensure the most appropriate status order is placed with the information known at the time.
• Monitors the bed request order placed by the Emergency Department Residents and members of the medical staff and recommends changes as needed based on utilization review.
• Completes all admission reviews within the shift as prioritized by team leadership and completes follow-up review timely and appropriately as required.
• Effectively provides outreach to any third party review company to ensure timely reviews and determinations of the patients hospital status.
• Partners with hospital Patient Throughput staff, medical staff and nursing leadership to coordinate bed placement that is appropriate with the patients clinical condition and the patients status order.
• Collaborates with the Payor Specialists, as needed, to effectively communicate all relevant information to the payor.
• Collaborates with the Social Work Team to communicate payor determinations and discuss the plan of care.
• Partners with operational and medical leadership in a given service line or team to identify, develop and implement successful communication, education, and processes to engage physicians and promote optimal clinical utilization.
• Queries medical staff as needed to ensure the appropriate level of care or hospital status is documented and assigned.
• Monitors the utilization of level of care designations, length of stay changes, avoidable days and readmissions through data analysis and reporting.
• Reviews and enters electronically appropriate clinical information based on payor guidelines.
• Ensures thorough, accurate and timely communication with the payor and communicates, among other data points, the patients clinical indicators and plan of care.
• Escalates cases as appropriate to the Quality Utilization Medical Directors or Lead Quality Utilization Specialists.
• Participates in interdisciplinary discharge planning rounds, bed planning huddles as needed to facilitate communication with the clinician care team.
• Participates in denial prevention strategies as advised by Quality Utilization Leadership.
• Collects data related to status changes and bed / unit changes at each shift as well as barriers encounters during said shift.

Implement surveillance and reporting to identify areas of concern and strength.

• Monitors internal and external trends to identify priorities.
• Sets and achieves appropriate goals for quality, patient safety, and innovation.
• Teaches / orients / trains nurses to the role and others as needed.
• Remains flexible in assignment coverage which includes working in routine Quality Utilization operations and in the non-Emergency Department environment, as needed, and at the direction of the Quality Utilization Leadership Team.
• Remains competent in the following areas regardless of payor type : utilization review criteria, observation carve outs, and denials prevention strategies.
• Ensures that Event Management in EPIC is accurate on every line at the time of each review.
• Uses data to drive decisions and plan, participate in and implement performance improvement strategies related utilization review outcomes.
• Maintain high levels of staff engagement and performance.
• Participates in the development, implementation, evaluation and revision of quality utilization tools in collaboration with healthcare team.
• Collaborates effectively across departments, including but not limited to directors and managers of quality / process improvement / analytics, chief medical officers, chief nursing executives, and operations executives.
• Actively participates on departmental and hospital committees and taskforces as assigned.
• Develops, coordinates, presents, and participates in service-line and clinician education programs.
• Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPAA requirements and Personal Rules of Conduct.

Qualifications

Required :

• Registered Nurse in the State of Illinois.
• Bachelor's degree in nursing.
• 2 years in Quality Utilization Specialist position or related role.
• Mastery of utilization management and level of care guidelines.
• Proven leadership skills to affect positive Quality Utilization outcomes.
• Statistics, quantitative and analytic skills relevant to the role.
• Analytical skills necessary to independently collect, analyze, and interpret data, resolve problems requiring innovative solutions and to negotiate in sensitive situations.
• High level of energy and enthusiasm; flexible / adaptable ability to work with diverse group of healthcare professionals in a matrix environment.
• Effective problem solving and multi-tasking, verbal and written communication skills.
• Basic computer skills including word processing and spreadsheets.

Preferred :

• 5+ years of relevant experience.
• Master's degree in Nursing.

Additional Information

Northwestern Medicine is an affirmative action / equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.