LOCATION: JOHN H. STROGER HOSPITAL / INTEGRATED CARE - CHICAGO, IL.
The Utilization Management Coordinator, Emergency Department (UMC) serves an important role to support Cook County Health & Hospitals System (CCHHS) goals of efficient, effective, patient-centric care. Using the electronic medical record (EMR) and consulting with the treatment team, the UMC determines if the patient is in the appropriate level of care and if clinical milestones are being met in a timely manner. The UMC provides timely feedback to the treatment team and makes appropriate referrals to other care coordination components for those patients who have barriers to discharge or whose condition requires a different level of care. The successful UMC has a sound clinical foundation, knowledge of utilization management, and critical thinking skills to support effective, timely communication regarding case status. This position requires days, evenings and weekend hours.
This position is exempt from Career Service under the CCHHS Personnel Rules.
Verifies payer status and medical home (documents same in notes)
Reviews cases being proposed for inpatient or observation at Stroger and Provident Hospitals within one hour of notification.
Provides continued stay review at intervals appropriate to the treatment plan and anticipated patient progress.
Review reflects the ability to:
o Translate signs, symptoms, lab values, diagnostic testing results, to a MCG guideline. For example the UMC is able to discern the origin of shortness of breath based on history, clinical presentation, vital signs and test results to select the appropriate guideline.
o Document all relevant information in case notes
o Detects and documents trends and in clinical and functional status data to assess patient progress
Correctly assigns medical necessity determination and level of care. If different than current assignment, notifies treatment team to alert them and provides recommendations.
Identifies and refers cases at risk-
o Readmissions within 30 days
o Failure to meet guidelines (either on initial or concurrent review)
o Multiple social determinants impacting care or treatment
o Active MH or SUD
o Those requiring on-going care coordination
o Managed Care Required care coordination
o Planned re-admission requiring pre-certification
Uses portals to forward clinical information to payers
Communicates succinctly and efficiently with stake-holders such as insurance companies, physicians, Inpatient Care Coordination Specialist,
Escalates case when EMR documentation doesn't support medical necessity requirement and outreach has not closed gaps.
Supports and organizes peer to peer conversations to avoid potential denials.
Participates in departmental quality improvement guidelines
Completes all educational efforts for CCHHS and licensure
Completes 25 reviews per day
Current License as a Registered Professional Nurse in the State of Illinois
Bachelor's Degree in Nursing from an accredited college or university (must provide official transcripts at time of interview)
Five (5) years of acute care, medical surgical, and/ or clinical experience as a registered nurse
One (1) year of utilization management experience
Must be able to type 30 word per minute with 80% accuracy (typing test required)
Successful completion of a Milliman Care Guidelines (MCG) Certification exam within 12 months of employment (Upon hire, the department will maintain responsibility to ensure the employee receives certification within the designated time)
In-depth clinical knowledge about common conditions including pathophysiology, standards of care, associated lengths of stay
When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service
To take advantage of this preference a Veteran must :
Meet the minimum qualifications for the position.
Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question,
The Cook County Health & Hospitals System’s mission is to deliver integrated health services with dignity and respect regardless of a patient’s ability to pay; foster partnerships with other health providers and communities to enhance the health of the public; and advocate for policies that promote the physical, mental and social wellbeing of the people of Cook County. CCHHS is comprised of two hospitals, John H. Stroger, Jr. Hospital and Provident Hospital, a robust network of more than a dozen community health centers, the Ruth M. Rothstein CORE Center, the Community Triage Center, the Cook County Department of Public Health, Cermak Health Services, which provides health care to individuals at the Cook County Jail and the Juvenile Temporary Detention Center, and CountyCare, a Medicaid managed care health plan.The system cares for more than 300,000 patients each year and its physicians are experts in their fields, committed to providing their patients with comprehensive, compassionate and cutting-edge care. Today, CCHHS is transforming the provision of health care in Cook County by promoting community-based primary and preventive care, growing an innovative, collaborative health plan and enhancing the patient experience.