Utilization Reviewer-Full Time On-Site

Company 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?

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

Utilization Reviewer – Behavioral Health Programs

Northwestern Medicine Ben Gordon Center
DeKalb, Illinois

Position Summary

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

Responsibilities

Utilization Review & Documentation Compliance

• 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.
• Assist 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.

Preferred Qualifications

• 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.

Ideal Candidate

The ideal candidate is highly organized, detail-oriented, and passionate about improving quality across behavioral health services. They are comfortable working across multiple programs simultaneously and thrive in environments focused on compliance, performance improvement, data-driven decision-making, and exceptional patient care.

This individual understands that strong utilization review processes protect both patients and programs by ensuring services remain clinically appropriate, properly documented, fiscally sustainable, and aligned with grant and regulatory expectations.

Schedule & Work Environment

• Full-time, Monday through Friday
• Standard 40-hour work week
• Flexible start time between 7:00 AM and 8:30 AM
• Eight-hour shifts with consistent weekday scheduling
• No routine weekend coverage required
• Primarily office-based with regular collaboration across behavioral health, quality, compliance, grant, and operational teams
• May participate in occasional meetings, trainings, audits, accreditation reviews, grant monitoring activities, and performance improvement initiatives
• Hybrid work opportunities may be considered after successful completion of onboarding and demonstrated competency in core job functions, in accordance with departmental needs and Northwestern Medicine policies.

Qualifications

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.

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.

Job Shift: Day Job (1st)Salary Range Minimum : $37.21Salary Range Maximum: $52.10 Compensation: USD 37.21 - USD 52.1 - hourly