Clinical Reviewer

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

📋 Description

• Assess clinical documentation to evaluate the medical necessity and appropriateness of requested services.

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

• Facilitate service coordination by connecting children, youth, and adults to both 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 using standardized, evidence-based criteria.

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

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

• Consult with physician or practitioner reviewers when cases fall short of meeting clinical review criteria.

• Refer cases to other clinicians when deemed appropriate.

• Offer clinical and utilization review subject matter expertise.

• Address questions or concerns from stakeholders.

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

• Provide guidance or supervision to non-clinical staff as necessary.

• Travel for in-person assessments throughout the assigned region.

• Perform other assigned duties.

⛳️ Requirements

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

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

• Applicants must reside in Oregon.

• Access to personal transportation and willingness to travel.

• Valid Driver's License and proof of auto insurance.

• Reliable and secure internet connection.

• Must maintain eligibility for licensure according to the assigned state contract.

• Experience with Medicaid is preferred.

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

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

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

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

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

• Exceptional oral and written communication skills.

• Strong interpersonal and problem-solving abilities.

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

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

• Ability to accurately and timely document utilization review determinations in designated systems.

• Competence 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 volunteering.

• Retirement savings plan with employer contributions.

• Financial assistance for adoption.

• Paid parental leave.

• Annual stipend to enhance workspace.

• Support for remote work.

• Emphasis on work-life balance.

• Reasonable accommodations for individuals with disabilities.