Utilization Review / Case Manager (RN)

Utilization Review / Case Manager (RN)

Chicago, Illinois Reports To: Clinical Director, Behavioral Health Services Term: Permanent, Full-time

General Summary

The Utilization Review/Case Manager facilitates appropriate use of hospital resources by ensuring that patients meet acute inpatient criteria and anticipates discharge needs in a timely manner. The role acts as a central communicator with external and internal customers, collaborating with social workers, case managers, vendors, payers, and community agencies.

Key Responsibilities

• Perform inpatient utilization management per plan, payer requirements, and standards.
• Collaborate with physicians and healthcare team members for timely and appropriate patient management.
• Collect and document clinical data to support admission and continued hospitalization.
• Provide accurate clinical information to payers as required.
• Support DRG Assurance Program with accurate data collection and assignment.
• Perform non-acute profiling, collect data on avoidable days, and refer cases to Physician Advisor when needed.

Discharge Planning

• Participate in family meetings and care conferences.
• Ensure timely referrals for discharge planning and use of regional/community resources.
• Refer complex cases to Social Services as appropriate.
• Ensure psychological needs of patients are met via direct intervention or referral.

Communication & Coordination

• Act as a central communicator with patients, families, vendors, payers, and hospital staff.
• Provide continuity of care by leveraging community resources and maintaining updated resource manuals.
• Refer cases not meeting criteria to Physician Advisor in a timely manner.
• Follow up with Medical Director/Physician Advisor on unresolved issues.

Other Duties

• Maintain safe patient care environment and infection control compliance.
• Manage departmental operations (phones, supplies, data tracking).
• Attend in-service presentations and complete all mandatory education.
• Perform other duties as assigned.

Knowledge, Skills & Abilities

• Graduate of an accredited school of nursing (Required)
• Current RN License in Illinois (Required)
• 2+ years relevant clinical experience (Preferred)
• Utilization management experience (Preferred)
• Knowledge of Medicare/Medicaid, Managed Care, and Commercial insurance processes (Preferred)
• Strong written/oral communication skills with appropriate grammar and vocabulary
• Proficiency in Microsoft Word and Excel (Required)
• Ability to provide excellent customer service at all times
• Ability to anticipate and coordinate multiple functions effectively