Clinical Reviewer

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

📋 Description

• Evaluate clinical documentation to confirm medical necessity and suitability 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 findings in designated systems.

• Collaborate with physician or practitioner reviewers when cases do not satisfy 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 with quality assurance activities, audits, and other program support.

• Provide guidance or oversight to non-clinical staff performing support tasks, as needed.

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

• Conduct functional needs assessments to evaluate how mental health symptoms affect daily living.

• Facilitate service coordination connecting children, youth, and adults to in-home and community-based care.

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

• Undertake additional duties as assigned.

⛳️ Requirements

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

• Minimum of 3 years of clinical experience (direct patient care); experience in behavioral health is preferred.

• Candidates must be residents of Oregon.

• Personal transportation with the ability to travel.

• A valid Driver's License and proof of auto insurance are necessary.

• A reliable and secure internet connection is required.

• Must maintain licensure eligibility for the assigned state contract.

• Familiarity with Medicaid may be advantageous.

• Knowledge of the Oregon behavioral health system of care is a plus.

• Two years of utilization review or other medical management experience may be beneficial.

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

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

• Strong organizational abilities and capacity to manage multiple tasks in a team setting.

• Excellent 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 evaluate medical necessity.

• Capability to document utilization review decisions accurately and timely in designated systems.

• Ability to provide clinical and utilization review subject matter expertise and address stakeholder inquiries.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off for vacation, illness, and volunteer work.

• Retirement savings plan with employer contributions.

• Financial assistance for adoption.

• Paid parental leave.

• Annual stipend to improve the workspace.

• Support for remote work.

• Emphasis on work-life balance.

• Reasonable accommodations for individuals with disabilities.