Major Responsibilities: Perform and document accurate and timely initial, concurrent, and retrospective reviews of the information available in the patients’ medical record to assess the severity of illness and intensity of service, ensure the plan of care and discharge plan align with the most up to date evidence-based, nationally accepted criteria, and the patients receive services in the most appropriate and cost effective setting Monitor the Inpatient, Observation, and Extended Outpatient cases for medical necessity criteria and communicate with members of the healthcare team to ensure timely orders for appropriate changes in patient status Identify the variances from the established plans of care, pathways, algorithms and guidelines, and collaborate with internal and external partners to facilitate the timely implementation of the appropriate action plan (e.g., submit Physician Advisor Referrals, file reconsideration requests with the payer, facilitate peer to peer reviews) as needed to decrease and/or prevent denials Document actions taken, and the pertinent communication regarding certification in the clinical database. Document avoidable days in the designated system. Report any quality of care concerns to the appropriate leadership for information and resolution as needed and promote patient safety by reporting issues through established channels and participating safety initiatives as needed/requested. Serve as a resource to the healthcare team regarding utilization standards and potential alternatives to acute care hospitalization. Serve as a liaison with external review agencies to insure compliance with regulations affecting financial reimbursement to the hospital, and timely submission of complete and accurate clinical review summary following HIPAA guidelines. Maintain up to date knowledge of current standards of care via literature review and/or participation in educational offerings. Maintain up to date knowledge and compliance with hospital policies, procedures, and regulatory agency standards. Incorporate the information and skills acquired in learning activities to improve patient outcome. Incorporate the role of educator into daily activities and facilitate the development of the multidisciplinary team members in the principles of care management.

Licensure:Nurse, Registered (RN)

Education/Experience Required:Level of Education: Bachelor's Degree in Nursing Years of Experience: 3+ Years of experience in clinical nursing, Utilization Review, case and/or quality management.

Knowledge, Skills & Abilities Required:Working knowledge in the use of Microsoft Office (Excel, Outlook, PowerPoint and Word) or similar products. Knowledge of the components of quality and acute care patient care needs specifically related to the area/function in which care management will be performed. Demonstrated working knowledge and accurate application of evidence based, nationally recognized Utilization Review criteria as evidenced by achieving 80% or greater on the annual InterRater Reliability (IRR) competency exam. Critical thinking skills to analyze and synthesize clinical scenarios as it relates to application of medical necessity criteria. Excellent analytical and interpersonal communication skills necessary to interact with colleagues, physicians, and third-party payers. Ability to foster and maintain effective professional relationships with physicians and other professionals in a direct and positive manner. Ability to manage conflict appropriately and communicating with others in a maner that alligs with Advocate Aurora’s Behaviors of Excellence Assume responsibility for self-development by seeking out opportunities for professional growth and development and being an active participant in department, hospital, and system initiatives. Ability to be flexible and function well in the everchanging, fast-paced, heavily regulated health care/payer environment, and to comply to expectation of strict adherence to predetermined procedures and processes, and compliance and privacy/HIPPA guidelines Ability to function well in a fast-paced work environment that involves numerous interactions with a wide variety and clinical and non-clinical team members, prioritize independently and manage and address timely multiple simultaneous requests License/Registration/Certification: Registered Nurse license in the state in which the team member practices

Physicial Requirements and Working Conditions: This position may requires travel, therefore, will be exposed to weather and road conditions. Ability to operate all equipment necessary to perform the job. Exposed to a normal office environment; including usual hazards related to operating electrical equipment. Manual dexterity required for operation computer and calculator and other equipment necessary to perform. Visual acuity required for facilitating review of written documents/computer screens, medical records, and to record information accurately. Clear verbal communications and hearing acuity required for receiving instructions and converse on standard telephone. Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.



This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.