Clinical Reviewer

This is a fully remote position, open to applicants in Oregon.

📋 Description

• Evaluate clinical documentation to verify medical necessity and appropriateness for requested services.

• Conduct initial and ongoing stay reviews utilizing standardized, evidence-based criteria.

• Implement clinical review criteria, organizational policies, guidelines, and screening tools to assess medical necessity.

• Accurately and promptly document utilization review decisions in designated systems.

• Collaborate with physician or practitioner reviewers when cases fail to meet clinical review criteria.

• Refer cases to other clinicians as necessary.

• Offer subject matter expertise in clinical and utilization review.

• Address questions or concerns from stakeholders.

• Assist in quality assurance activities, audits, and other program support initiatives.

• Provide guidance or oversight to non-clinical staff engaged in support activities.

• Manage referrals, follow-ups, reviews, and assessments within an electronic medical record system.

• Conduct functional needs assessments and facilitate service coordination.

• Travel for in-person assessments across the designated region as required.

• Perform additional duties as assigned.

⛳️ Requirements

• Current, active, unrestricted clinical licensure as mandated by the Oregon contract, such as LCSW, LPC, or LCPC.

• A minimum of 3 years of direct clinical patient care experience; behavioral health experience is preferred.

• Candidates must reside in Oregon.

• Personal transportation and the capability to travel.

• Valid driver's license and proof of auto insurance.

• Reliable and secure internet connection.

• Maintain eligibility for licensure under the assigned state contract.

• Experience with Medicaid is preferred.

• Familiarity with the Oregon behavioral health system of care is preferred.

• A minimum of 2 years of utilization review or other medical management experience is preferred.

• At least 2 years of full-time experience in substance use disorder and/or behavioral health disorder is preferred.

• Proficiency in clinical documentation review, including knowledge of the Oregon Health Plan Prioritized List of Health Services and InterQual.

• Strong organizational abilities and capacity to manage multiple tasks in a team-oriented environment.

• Exceptional oral and written communication skills.

• Strong interpersonal and problem-solving capabilities.

• Proficiency in MS Office Suite and familiarity with database software.

• Ability to apply clinical review criteria, policies, and guidelines to assess medical necessity.

• Capability to accurately and promptly document utilization review determinations.

• Ability to provide subject matter expertise in clinical and utilization review.

• Ability to sit for extended periods and communicate effectively.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off for vacation, illness, and volunteering.

• Retirement savings plan with employer contributions.

• Financial assistance for adoption.

• Paid parental leave.

• Annual stipend to enhance workspaces.

• Support for remote work.

• Opportunities to maintain work-life balance.

• Reasonable accommodations for individuals with disabilities.