Lead ED Quality Utilization Specialist, Full-time, Days ( 4,000 sign-on bonus)

📋 Description

• • Serve as the strategic leader and clinical authority for Emergency Department quality and utilization management across Northwestern Medicine’s high-acuity, 90,000-visit ED, owning every metric from door-to-discharge and ensuring patients receive the right care, in the right place, at the right cost.
• • Transform complex clinical and financial data into clear, actionable insights by designing and maintaining real-time dashboards in Epic, Tableau, and SQL that track length-of-stay outliers, avoidable admissions, imaging/lab over-utilization, and payer denial patterns—then translate those insights into concise, persuasive narratives that drive physician and nursing behavior change.
• • Chair daily multidisciplinary huddles and weekly Utilization Review Committee meetings, facilitating evidence-based dialogue among physicians, case managers, social workers, and finance partners to optimize observation versus inpatient status, expedite safe discharges, and prevent costly denials before they occur.
• • Act as the clinical gatekeeper for all Level-1 trauma activations, high-cost imaging requests, and inpatient admission orders, completing evidence-based reviews within 60 minutes of patient arrival; provide real-time coaching to residents, advanced practice providers, and attending physicians to strengthen documentation and medical-necessity justification.
• • Lead enterprise-wide quality initiatives—Sepsis Core Measure compliance, CMS SEP-1 bundle adherence, ED throughput improvement, and readmission reduction—establishing project charters, success metrics, and national benchmarking (Vizient, Premier) that are adopted across the entire Northwestern Medicine system.
• • Partner with Revenue Cycle leadership to reduce denial-related write-offs by at least 15% year-over-year, leveraging deep expertise in InterQual, MCG, and payer-specific medical-necessity criteria to overturn denials at the first level and avoid costly appeals.
• • Directly supervise and mentor a team of 4–6 Utilization Review Coordinators, creating individualized development plans, conducting quarterly performance reviews, and ensuring 100% of staff maintain current RN licensure and relevant certifications (CCM, CCDS, ACM).
• • Champion a culture of safety and continuous learning by conducting monthly case reviews of sentinel events, near misses, and patient complaints; distill findings into five-minute micro-learning modules delivered during shift huddles to embed best practices into daily workflow.
• • Represent the Emergency Department on system-level committees including Quality Council, Ethics Board, and Care Management Steering Committee, translating frontline realities into policy, procedure, and technology enhancements that improve both patient outcomes and provider experience.
• • Manage an annual $2.5 million observation-services budget, ensuring every dollar is allocated to patients who meet strict medical-necessity criteria while identifying opportunities to shift appropriate cases to lower-cost settings such as clinical decision units or home-based care.
• • Collaborate with telehealth vendors and rural referral hospitals to pilot virtual admission reviews and e-consults, expanding access to Northwestern’s specialty expertise while reducing unnecessary inter-facility transfers by an estimated 20%.
• • Serve as the primary liaison for regulatory surveys from CMS, The Joint Commission, and state health departments; maintain meticulous documentation and deliver confident on-the-spot explanations that safeguard Level-1 trauma verification, Comprehensive Stroke Center certification, and payer contracts.
• • Influence long-term strategic planning by forecasting ED demand 12–18 months in advance, incorporating seasonal disease patterns, demographic shifts, and payer-mix changes so that staffing, bed capacity, and supply-chain decisions are proactive, data-driven, and financially sound.
• • Celebrate and broadcast wins across the department—whether a 10-point Press Ganey improvement, a successful denial overturn, or a resident who masters sepsis documentation—because visible recognition accelerates the cultural transformation you are hired to lead.