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.

• Complete functional needs assessments to determine how mental health symptoms impact daily living.

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

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

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

• Collaborate with physician or practitioner reviewers when cases do not align with clinical review criteria.

• Refer cases to other clinicians as necessary.

• Provide expertise in clinical and utilization review and address stakeholder inquiries or concerns.

• Assist with quality assurance activities, audits, and other program support tasks.

• Offer guidance or oversight to non-clinical staff as needed during support activities.

• Travel for in-person assessments within the assigned 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 clinical direct patient care experience; behavioral health experience is preferred.

• Must be a resident of Oregon.

• Personal transportation and ability to travel are required.

• Valid driver’s license and proof of auto insurance are mandatory.

• Reliable and secure internet connection is necessary.

• Must maintain licensure eligibility for the designated state contract.

• Experience with Medicaid is preferred.

• Knowledge of the Oregon behavioral health system of care is preferred.

• Desired experience includes 2 years in utilization review or other medical management roles.

• Desired experience should include 2 years of full-time substance use disorder and/or behavioral health disorder work.

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

• Strong organizational skills with the ability to manage multiple tasks in a team setting.

• Excellent oral and written communication abilities.

• Strong interpersonal and problem-solving skills.

• Proficient in MS Office Suite and familiar with database software.

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

• Capability to document utilization review determinations accurately and in a timely manner.

• Ability to provide clinical and utilization review expertise and address stakeholder inquiries or concerns.

• Capacity 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 workspace.

• Support for remote work.

• Reasonable accommodations for individuals with disabilities.