Utilization Review RN-UR Casual Rotating Shift

Northwestern Memorial Healthcare•Lake Forest, IL

5d•Onsite

About The Position

The Utilization Review RN is a casual position supporting Utilization Review at Catherine Gratz Griffin Lake Forest Hospital. The role provides additional departmental staffing coverage and has no set schedule. Candidates should be available to work weekdays and weekends. Shifts are scheduled from 6 a.m. to 6 p.m. or 6 p.m. to 6 a.m. The Case Manager, RN (PT) upholds Northwestern Medicine’s mission, vision, values, Code of Ethics, and Corporate Compliance Program while following applicable policies, procedures, regulatory requirements, and accreditation standards. The role reviews medical records and admission status, supports appropriate utilization of care, coordinates discharge planning and transitions, monitors compliance and documentation, and assists with appeals and denials.

Requirements

Registered Nursing license issued by the State of Illinois.
Bachelor of Science in Nursing.
Three or more years of related clinical experience.

Nice To Haves

Master of Science in Nursing.
Membership in a professional nursing organization.
Certification in Case Management (ACM).

Responsibilities

Develop individualized treatment plans in collaboration with patients and their families.
Coordinate and lead care conferences for patients whose length of stay exceeds seven days.
Document unusual occurrences and patient relations issues, and make appropriate referrals to risk management, infection control, and quality departments.
Assess patient and family needs for appropriate discharge services.
Coordinate transfers to appropriate levels of care, including skilled care, rehabilitation, custodial care, and home health care.
Document discharge planning in the interdisciplinary plan of care, progress notes, and education record.
Maintain current knowledge of community resources that support continuity of effective patient services.
Deliver notices of Medicare discharge appeal rights within the appropriate timeframe.
Assist physicians in assigning admission status.
Review medical records to assess the appropriateness of admissions and continued hospital stays.
Monitor avoidable days and recommend changes to services or processes.
Educate staff on CPGs, standing orders, and protocols that support industry standards, reduce length of stay and resource consumption, and maintain quality of care.
Ensure compliance with managed care contracts and length-of-stay targets while maintaining quality of care.
Develop and educate staff on CPGs, standing orders, and protocols that support industry standards, reduce length of stay and resource consumption, and maintain quality of care.
Distribute hospital-issued noncoverage notices.
Monitor documentation of appropriate diagnoses for outpatient and observation testing, and query physicians or APPs as needed following AHIMA guidelines.
Respond to patient financial services requests for appeal assistance.
Support the Denials Lead RN with appeals of insurance denials for medical necessity for inpatient and outpatient services.
Complete documentation worksheets.
Query physicians for clarification or missing documentation.
Conduct chart audits for documentation compliance with CMS standards.
Obtain appropriate documentation to comply with core measure standards.