Utilization Reviewer-Full Time On-Site

Job Description

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

Full-time, Monday through Friday Standard 40-hour work week Flexible start time between 7:00 AM and 8:30 AM

Responsibilities

• Conduct concurrent, prospective, and retrospective utilization reviews of clinical records.
• Review documentation for compliance with Medicaid, grant, accreditation, payer, and program-specific requirements.
• Audit assessments, treatment plans, IM+CANS, IATPs, progress notes, discharge documentation, and other clinical records.
• Monitor timeliness, completeness, and quality of documentation.
• Identify trends in documentation deficiencies and recommend corrective actions.
• Collaborate with clinical leaders to improve documentation quality and compliance outcomes.
• Provide education, coaching, and technical assistance to staff regarding documentation standards and requirements.
• IM+CANS & IATP Oversight
• Monitor compliance with IM+CANS and IATP requirements across applicable programs.
• Review clinical records to ensure assessments support treatment planning and medical necessity.
• Evaluate documentation for consistency between assessment findings, diagnosis, treatment goals, interventions, and outcomes.
• Assist with implementation of workflow improvements related to assessment and treatment planning processes.
• Grant Compliance & Performance Monitoring
• Support monitoring of state, federal, local, and private grant deliverables.
• Track program performance measures, contractual outcomes, and quality indicators.
• Assist leaders with collection, validation, and reporting of program performance data.
• Participate in preparation for grant reviews, monitoring visits, audits, and fiscal administration reviews.
• Collaborate with grant managers and program leaders to identify improvement opportunities when performance measures are not being achieved.
• Quality Improvement & Analytics
• Analyze utilization review findings and performance data to identify trends, risks, and opportunities.
• Develop routine reports and dashboards for leadership review.
• Participate in quality improvement initiatives and performance improvement projects.
• Aid in the development and monitoring of corrective action plans.
• Support organizational readiness for accreditation, state reviews, and regulatory audits.
• Cross-Functional Collaboration
• Work closely with clinical managers, directors, compliance staff, patient access teams, revenue cycle staff, grant managers, and analytics personnel.
• Participate in interdisciplinary meetings focused on compliance, quality, grant performance, and clinical operations.
• Serve as a resource regarding documentation standards, medical necessity, and service requirements.

Qualifications

• 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.

Additional Information

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.