Job Description
PRN/As Needed position
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.
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.
- Behavioral Health experience
Additional Information
Northwestern Medicine is an affirmative action/equal opportunity employer 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.
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.
