Description

The Utilization Management Lead 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.

The Utilization Management Lead collaborates with the director of care coordination to oversee the utilization Review and Management process in accordance with NM Central DuPage Hospital’s UM Plan and operations of the UR team. This position serves in a lead role by utilizing communication skills to build trusting interdisciplinary relationships, engaging in conflict management, coaching, mentoring, and staff development, and fosters an environment for shared decision making.

Responsibilities:

• Collaborates with the director of care coordination to provide the utilization review team with an environment that supports their professional practice, health and well-being.
  • Coaches and mentors and develops utilization review nurses in their professional practice.
  • Collaborates with director and department secretary to ensure appropriate and complete orientation of new staff. Identifies appropriate preceptor(s) and assigns schedule to new staff.
  • Collaborations with UR staff, physicians, payers, revenue cycle, denials team, and managed care team to ensure resources are coordinated to meet the needs of patients and the organization.
  • Gains and maintains knowledge of utilization management to assure current best practice standards and compliance with Federal, State and regulatory agency requirements.
  • Contributes to annual employee performance evaluation and is present when evaluation is given.
• Serves as the Utilization Management expert and collaborates with the director of care coordination for the implementation of evidence based practice.
  • Practices Utilization Review and Denials management in the care coordination department.
  • Coordinates the daily operations of the utilization management department.
  • Performs audits to ensure optimal performance and compliance with regulatory requirements.
  • Collaborates with the interdisciplinary team in care coordination
  • Ensures process improvement initiatives are sustained. 
  • Facilitates the development and implementation of evidence-based practice projects
• Customer Focus:
  • Clearly identifies the internal and external customer(s) for their unit or service area and their respective requirements/expectations.
  • Actively seeks methods of concurrent and retrospective feedback from customers, listens to customer feedback and implements solutions and/or interventions as appropriate.
  • Continually examines ways to improve business relationships with customers, suppliers, and the community
• Creative Leadership:
  • Translates organizational vision into a unit or service area vision that engages team members in contributing to and achieving that vision.
• Coaching and Development:
  • Provides feedback to improve employee performance and engagement
• Continuous Learning:
  • Seeks new ideas from a wide range of sources; encourages others to share knowledge and best practices.
  • Maintains active membership in Professional Organization and shares current, relevant information

Qualifications

Required:

• Graduate of an accredited school of nursing with a BSN
• Minimum of three years of case management experience in an acute care setting or health care environment

Preferred:

• ACM certification
• Master’s degree

Equal Opportunity

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.