Ann & Robert H. Lurie Children’s Hospital of Chicago provides superior pediatric care in a setting that offers the latest benefits and innovations in medical technology, research and family-friendly design. As the largest pediatric provider in the region with a 140-year legacy of excellence, kids and their families are at the center of all we do. Ann & Robert H. Lurie Children’s Hospital of Chicago is ranked in all 10 specialties by the U.S. News & World Report.

Day (United States of America)

Ann & Robert H. Lurie Children's Hospital of Chicago

Consistently applies the utilization management process as required by the Code of Federal Regulations, including the use InterQual Evidenced Based Medical Necessity criteria for primary review. Incorporates into the utilization management process the ability to access and interpret clinical information against InterQual Evidenced Based Medical Necessity criteria to reach correct admission status determinations. Has the current knowledge of applicable regulations and laws pertaining to the major payers including Medicare, Medicaid, and other payers. Works with the interdisciplinary team to ensure that the care and services provided are medically necessary, delivered efficiently and timely, and at the appropriate level of care to meet payer requirements and established financial and performance benchmarks. The role reflects appropriate knowledge of RN scope of practice, current state requirements, CMS Conditions of Participation, EMTALA, and other Federal or State regulatory agency requirements specific to Utilization Review.

1. Communicates with Admitting or PFS regarding the needs of the patient, payer and provider.
2. Communicates relevant elements of the patient's health plan benefits.
3. Completes medical necessity utilization reviews and documents those reviews in MIDAS+ within required timeframes.
4. Reviews every inpatient admission and observation order for appropriateness based on InterQual Evidenced Based criteria within the required timeframes and follows the approved utilization review procedures if the patient status order is not consistent with the medical necessity assessment.
5. Notifies Admitting Department of errors or needed changes in patient data including changes in physician orders/incorrect admission status designation.
6. Reviews record including physician orders and documents admission, concurrent, discharge reviews and retrospective reviews as assigned.
7. Communicates with physicians regarding the level of care or admission status when appropriate criteria are not met for inpatient, observation or continued stay.
8. Refers cases to the Case Management leadership and/or Case Management Medical Director as needed and documents the referral.
9. Provides and documents concurrent reviews or other information requested by the payer within required timeframes.
10. Demonstrates responsibility for professional development and growth including identifying continuing education needs and seeking learning opportunities that will enhance job performance and professional satisfaction.
11. Demonstrates compliance with facility and departmental safety and security policies and practices.
12. Educates hospital team members and physicians about the Utilization Management RN and scope of practice.
13. Supports the hospital quality, risk and performance improvement programs.
14. Other job functions as assigned.

Knowledge, Skills and Abilities:

1. RN licensure in the state of Illinois.

2. BSN or higher required.

3. Certification in Case Management (CCM) or willing to obtain after 1 year

4. Experience with InterQual and Midas+ preferred.

5. Two to four years relevant clinical experience as an RN, current knowledge of health care trends and practices related to pediatric healthcare and case management.

6. Working knowledge of hospital revenue cycle and payer reimbursement methodologies

7. Experience working in partnership with healthcare professionals and support staff.

8. Strong problem solving skills.

9. Demonstrates flexibility and ability to adjust in a changing environment.

10. Proficiency with Word, Outlook, Excel, PowerPoint, and other database tools/applications.

11. Excellent written and verbal communication skills.

12. Potential to work from home after 12 months of service at Ann & Robert H. Lurie Children's Hospital of Chicago.

Education

Pay Range

$83,200.00-$137,280.00 Salary

At Lurie Children’s, we are committed to competitive and fair compensation aligned with market rates and internal equity, reflecting individual contributions, experience, and expertise. The pay range for this job indicates minimum and maximum targets for the position . Ranges are regularly reviewed to stay aligned with market conditions. In addition to base salary, Lurie Children’s offer a comprehensive rewards package that may include differentials for some hourly employees, leadership incentives for select roles, health and retirement benefits, and wellbeing programs. For more details on other compensation, consult your recruiter or click the following link to learn more about our benefits.

Benefit Statement

For full time and part time employees who work 20 or more hours per week we offer a generous benefits package that includes:

Medical, dental and vision insurance

Employer paid group term life and disability

Employer contribution toward Health Savings Account

Flexible Spending Accounts

Paid Time Off (PTO), Paid Holidays and Paid Parental Leave

403(b) with a 5% employer match

Various voluntary benefits:

• Supplemental Life, AD&D and Disability

• Critical Illness, Accident and Hospital Indemnity coverage

• Tuition assistance

• Student loan servicing and support

• Adoption benefits

• Backup Childcare and Eldercare

• Employee Assistance Program, and other specialized behavioral health services and resources for employees and family members

• Discount on services at Lurie Children’s facilities

• Discount purchasing program

There’s a Place for You with Us

At Lurie Children’s we embrace and celebrate diversity and equity in a serious way. We are committed to building a team with a variety of backgrounds, skills, and viewpoints — recognizing that diverse identities strengthen our workplace and the care we can provide to the Chicago community and beyond. We treat everyone fairly, appreciate differences, and make meaningful connections that foster belonging and allyship. This is a place where you can be your best, so we can give our best to the patients and families who trust us with their care.  

Lurie Children’s and its affiliates are equal employment opportunity employers.  We value diversity and are committed to creating an inclusive environment for all employees.  All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity or expression, religion, national origin, ancestry, age, disability, marital status, pregnancy, protected veteran status, order of protection status, protected genetic information, or any other characteristic protected by law.

Support email: [email protected]