Utilization Reviewer-Full Time On-Site

Northwestern Memorial Healthcare•Sycamore, IL

1d•$37 - $52•Onsite

About The Position

The Utilization Reviewer for Behavioral Health Programs reflects the mission, vision, and values of Northwestern Medicine, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all applicable policies, procedures, regulatory standards, and accreditation requirements. This position provides utilization review, documentation auditing, performance monitoring, and grant compliance support across a diverse portfolio of behavioral health programs. The Utilization Reviewer partners with leadership, clinical staff, quality teams, and grant managers to promote high-quality clinical documentation, regulatory compliance, financial sustainability, and achievement of program outcomes. The role supports multiple behavioral health service lines, including but not limited to: Crisis Continuum of Care Programs, Living Room Program, Mobile Crisis Response Team, Police Social Work Program, Outpatient Mental Health Services, Addiction Services, Community Support, Case Management, and Employment Programs, Grant-Funded Behavioral Health Initiatives and Programs, IM+CANS, IATP, and Treatment Plan Documentation Processes, Medicaid Rule 132 and Rule 2060 Programs, Certified Community Behavioral Health Clinic (CCBHC) initiatives.

Requirements

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

Nice To Haves

Experience conducting utilization review, quality assurance, compliance monitoring, or chart auditing within a Community Mental Health Center (CMHC) or Certified Community Behavioral Health Clinic (CCBHC).
Experience with Illinois Medicaid Rule 132 and/or Rule 2060 programs.
Knowledge of behavioral health accreditation, regulatory, and payer requirements.
Experience with IM+CANS, IATP, treatment planning, and behavioral health documentation standards.
Experience supporting state and/or federal grant-funded behavioral health programs.
Experience tracking contractual deliverables, quality indicators, and performance measures.
Experience with EPIC or other behavioral health electronic health record systems.
BSN with RN License.
CERT BLS, CERT CADC, CERT CSADC, LIC CPC, LIC LCSW, LIC MSW, LIC RN.

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.
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.
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.
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.
Assist in the development and monitoring of corrective action plans.
Support organizational readiness for accreditation, state reviews, and regulatory audits.
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.