Utilization Management and Population Health Nurse

Humboldt Park Health•Chicago, IL

About The Position

This role involves utilization case review and application of criteria to approve initial and continued inpatient services. The nurse will identify patients needing outreach based on risk stratification or disease management guidelines. They will collaborate with the CPHO team, Primary Care Physician, and other providers to create individualized care plans. Responsibilities include facilitating communication, coordinating referrals, and promoting optimal resource allocation. Progress will be measured using clinical judgment, patient self-monitoring tools, and clinical data trends. The nurse will assess and monitor adherence to outreach, problem-solve barriers to self-management, and provide educational materials. Referrals to self-management support programs and communication with care providers for safe care management are also key. Analyzing clinical data to track patient outcomes and improve them is essential. The role also includes triaging patient phone calls for acute issues and managing population health quality improvement studies to meet targets. Interaction with Commercial and Government entities on care coordination, HEDIS, and other QI activities is expected. Reporting to the UM/QM Committee on progress and recommendations is also part of the role. Other duties as assigned.

Requirements

Minimum qualifications must be health plan requirements, including but not limited to licensure/certification, as applicable.

Responsibilities

Conduct utilization case review and apply criteria to approve initial and continued inpatient services.
Identify patients in need of outreach efforts based on patient risk stratification or other defined criteria as well as defined disease management guidelines.
Work with CPHO team, patient’s Primary Care Physician and all other providers of the patients’ care to develop individualized care plans.
Facilitate communication with patients and care team, coordinate referrals, and promote optimal allocation of available resources.
Measure progress toward goals based on clinical judgment, review of patients’ self-monitoring tools and trends in clinical data.
Assess and monitor adherence to outreach and then problem-solve intrinsic and extrinsic barriers to effective patient self-management of chronic conditions.
Provide educational materials and resources to patient/family and their care providers.
Refer patients/families to self-management support programs as needed and communicate with care providers to ensure safe and effective care management.
Analyze clinical data to track patient outcomes to determine improvement.
Triage patient phone calls for acute patient issues and counsel accordingly.
Oversight and management of population health quality improvement studies to reach established targets.
Interface with Commercial and Government entities on care coordination, HEDIS and other QI activities.
Report to UM/QM Committee on progress toward goals and make recommendations for improvement.
Perform other duties as assigned.