Clinical Reviewer

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

📋 Description

• Analyze clinical documentation to assess the medical necessity and suitability of services.

• Conduct functional needs assessments to evaluate the impact of mental health symptoms on daily living.

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

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

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

• Implement clinical review criteria, organizational policies, guidelines, and screening tools.

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

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

• Refer cases to other clinicians as needed.

• Offer clinical and utilization review subject matter expertise.

• Address questions or concerns from stakeholders.

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

• Provide guidance or supervision to non-clinical staff involved in support activities, as necessary.

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

• Carry out additional duties as assigned.

⛳️ Requirements

• Current, active, unrestricted clinical licensure as mandated by the Oregon contract (e.g., behavioral health licensure such as LCSW, LPC, LCPC).

• Minimum of 3 years of clinical (direct patient care) experience.

• Candidates must be residents of Oregon.

• Personal transportation and the ability to travel are essential.

• A valid Driver License and proof of Auto Insurance are required.

• A reliable and secure internet connection is necessary.

• Must maintain licensure eligibility for the assigned state contract.

• Experience with Medicaid is preferred.

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

• 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 desired.

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

• Strong organizational skills and the capability to manage multiple tasks in a team setting.

• Excellent oral and written communication abilities.

• Strong interpersonal and problem-solving skills.

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

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

• Capability to document utilization review determinations accurately and promptly in designated systems.

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

🏝️ Benefits

• Medical, dental, and vision insurance.

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

• Retirement savings plan with employer contribution.

• Financial assistance for adoption.

• Paid parental leave.

• Annual stipend to enhance workspace.

• Remote work opportunity from anywhere in the U.S.

• Improved work-life balance.

• Reasonable accommodations for individuals with disabilities.