Utilization Reviewer-Full Time On-Site

Northwestern Memorial Healthcare; DeKalb (IL); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Tuition reimbursement

Loan forgiveness

401(k) matching

Lifecycle benefits

Job summary

Northwestern Medicine is seeking a qualified Utilization Reviewer to support pre-certifications, continued stays, discharge planning, and appeals. This role collaborates with clinicians and insurance companies to advocate for patient access to care.

Required: Master’s in Social Work or Psychology or BSN with RN license and at least 2 years of experience. Knowledge of DSM diagnoses and ASAM criteria is preferred. We offer competitive benefits and a clear pathway for professional growth.

Qualifications

• Minimum 2 years of experience in utilization review or equivalent.
• Master's in Social Work or Psychology or BSN with RN license.
• Experience communicating with physicians, insurers, and managed care teams.

Responsibilities

• Conduct utilization review calls, including precertification, continued stay, discharge, and retrospective reviews.
• Collaborate with business office staff, clinicians, and physicians to advocate for patients with insurers.
• Explain benefits and approval status to clinical staff, patients, and families as needed.
• Coordinate reviews with Utilization Review Coordinator and staff to minimize financial risk for patients and facility.
• Interface with insurance reviewers, employers, and plans to support approval and denial processes.

Skills

Utilization review

Healthcare coordination

DSM familiarity

Education

Master's Degree in Social Work or Psychology

BSN with RN License

Tools

ASAM criteria

DSM diagnoses

Job description

At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. This patient-first approach is what sets us apart as a leader in the healthcare industry. As an integral part of our team, you'll have the opportunity to join our quest for better health care, no matter where you work within the Northwestern Medicine system. We pride ourselves on providing competitive benefits: from tuition reimbursement and loan forgiveness to 401(k) matching and lifecycle benefits, our goal is to take care of our employees. Ready to join our quest for better?

Required: Master's Degree in Social Work or Psychology or BSN with RN License.

The Utilization Reviewer 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.

Responsibilities

• Responsible for utilization review calls within BHS, including precertification, continued stay review, discharge reviews, and retrospective reviews and appeals.
• Under the direction of the Utilization Review Coordinator, works closely with business office staff, clinical staff, and physicians to advocate for BHS patients with insurance and managed care companies.
• Familiar with and understands DSM diagnoses and ASAM patient placement criteria to communicate patient status to external managed care.
• Communicates insurance input to physicians and clinical staff making discharge plans for patients. Assists clinical staff with assessments as needed, primarily as in a back-up capacity.
• Communicates daily with Utilization Review Coordinator, and as needed with business office and admissions staff to understand admissions and transfers, patient benefit information, and precertification status, including making precertification or notice of admission calls on patients directly to minimize financial risk to patient and facility.
• Understands health care benefit plan provisions and managed care contracting, and communicates benefits and approval status of patients to clinical staff and physicians, and to patients and family members when needed.
• Serves as professional representative of BHS when interacting with reviewers from insurance companies, employers, and managed care plans, and contributes to BHS marketing strategies.
• Communicates and coordinates efforts at appealing unfavorable utilization review decisions, scheduling physician reviews, and monitoring denials and appeals, reporting to Utilization Review Coordinator. EOE Minorities/Women/Disabled/Veterans. VEVRAA Federal Contractor.

Required

• 2+ years of experience.
• Master's Degree in Social Work or Psychology or BSN with RN License.

Preferred

• BSN with RN License. CERT BLS, CERT CADC, CERT CSADC, LIC CPC, LIC LCSW, LIC MSW, LIC RN.

Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.

Background Check

Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.

Benefits

We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.

Sign-on Bonus Eligibility (if sign-on bonus offered for position)

Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family.