The Lead ED Quality Utilization Specialist 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 Lead ED Quality Utilization Specialist has achieved a mastery of utilization review principles and facilitates improvement in the overall completeness and accuracy of medical necessity, level of care and hospital status assignment. The Lead ED Quality Utilization Specialist applies clinical and utilization review expertise, knowledge of the national quality agenda, professional nursing standards, best practices, and interdisciplinary collaboration to assist in the accuracy assessment of utilization review functions that have been performed. The Lead partners with Hospital Throughput, Inpatient Nursing, the Emergency Department treatment team, and the clinical care team to help promote the most accurate level of care or hospital status and ensure the patient is assigned the most appropriate type of unit given the best-known hospital status at the time. These determinations are made with the information/labs/results and assessments at that given time and is a dynamic process.
The Lead ED Quality Utilization Specialist acts as a change agent to systematically drive and implement change as prioritized by Quality Utilization leadership, the Quality Utilization Committee and senior hospital and clinical leadership. The Lead participates in performance improvement initiatives, receives and monitors control plans and data trends under review of the Quality Utilization Team and in collaboration with clinician practices. The key to this role is the ability to lead and facilitate with key stakeholders, as well as oversee and coach the QU ED team members through complex projects and difficult conversations.
Responsibilities:
- Partners with current senior leadership to act as a change agent to methodically prioritize and execute workflow as designated by Quality Utilization Leadership, the Quality Utilization Committee and senior hospital/clinical leadership to navigate decisions at risk for conflict and evaluate immediate destination of patients to determine whether urgent interventions were ineffective.
- Partners with ED physicians, APPs, admitting team and the Patient Throughput Coordinators (PTCs) to assign an initial level of care and influence patient bed placement location when appropriate.
- Acts as a change agent to lead timely assessment and conversion of ED patient status to Observation with key stakeholders.
- Intervenes to reevaluate immediate destination of patient and/or for patients that fail to meet immediate disposition criteria.
- Navigates challenging conversations with MDs, APPs, Leads and administrative team members in an effort to determine the most accurate initial status and subsequent bed placement and escalates trends as appropriate. Proactively navigates patient care scenarios that are at-risk for conflict.
- Responsible for initiatives leading to cross-departmental change and program enhancements; the Lead QUS ED anticipates issues, interprets internal/ external issues and helps lead problem resolution.
- Leads QUS ED team in identifying priority observation reviews after bed change.
- Provides formal and informal ongoing education to ED Residents, APPs, and Medical Staff
- Charters process improvement initiatives and committees to address areas of conflict and to address areas of opportunity for improvement and/or RCA of case outcome.
- Escalates cases as appropriate to the Quality Utilization Medical Directors or leadership for second level review as appropriate.
- Assists novice Quality Utilization Specialist, ED in execution of status determinations.
- Acts as a mentor for the entire QU department, and fosters an environment of collaboration across the team.
- Performs medical record reviews and other data collection activities that assist in identifying possible documentation issues and/or status inaccuracies for improvement.
- Assists Quality Utilization Nurse Auditor to develop standards, participate in ongoing ED audit process, monitor ED competencies, provide feedback and to re-evaluate clinical audit tools as needed.
- Applies knowledge of professional practice, QU standards, Best Practices and interdisciplinary collaboration for problem analysis, resolution and creative process redesign. Leverages NMH network to initiate conversations, identify root causes and resolution and align resources.
- Responsible to lead QU efforts in support of NMH strategical initiatives under direction of QU and Patient Care Leadership.
- Analyzes case review data to accurately identify trends that require improvement.
- Instructs QU team/ ED team and distributes updated information on Level of Care, Status Order, Federal rule changes and other QU concepts.
- Partners with other QU Leads to coach and teach colleagues on all areas of QU and independently assists with onboarding of new staff to QU.
- Collaborates with QU Manager for onboarding and interviewing QUS candidates
- Drives creative process redesign and continuous reevaluation of effectiveness of current processes and interactions with key stakeholders
- Remains flexible in assignment coverage which includes working in routine Quality Utilization operations and in the non-Emergency Department environment, as needed, and at the direction of the Quality Utilization Leadership Team. This also includes flexibility of weekend coverage and nontraditional office hours.
- Remains competent in the following areas regardless of payor type: utilization review criteria, observation carve outs, inpatient/observation reviews, and denials prevention strategies.
- Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct.