Utilization Reviewer PRN-Behavioral Health

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 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. Qualifications 2+ years of experience. Master's Degree in Social Work or Psychology or BSN with RN License. BSN with RN License. CERT BLS, CERT CADC, CERT CSADC, LIC CPC, LIC LCSW, LIC MSW, LIC RN. Benefits Northwestern Medicine is committed to providing competitive benefits, including tuition reimbursement, loan forgiveness, 401(k) matching and other lifecycle benefits. The company also offers a wide range of benefits that support physical, emotional and financial well‑being. Sign‑On Bonus Eligibility Internal employees and rehires who left Northwestern Medicine within one year are not eligible for the sign‑on bonus. Exceptions apply for new graduate internal employees seeking their first licensed clinical position at NM, depending on the job family. Equal‑Opportunity Statement 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. #J-18808-Ljbffr