Behavioral Health Case Manager/ Clinical Reviewer (Oregon)

COMAGINE HEALTH•Remote, US,

5d•$76,000 - $89,000•Remote

About The Position

This role involves reviewing clinical documentation to determine the medical necessity and appropriateness of behavioral health services. Responsibilities include completing functional needs assessments to evaluate how mental health symptoms impact daily living, and supporting service coordination to connect individuals with in-home and community-based care. The position requires managing referrals, follow-ups, reviews, and assessments within an electronic medical record system, applying evidence-based criteria to utilization management reviews, documenting clinical determinations, providing subject matter expertise to stakeholders, and supporting quality activities and audits. Travel for in-person assessments may be required across the assigned region in Oregon. Candidates should demonstrate strong clinical judgment, relationship-building skills, and the ability to manage a high-volume workload effectively. A collaborative mindset, accountability, curiosity, and comfort with technology are also important. Administrative tasks are conducted using company-issued equipment.

Requirements

QMHP OR current, active, unrestricted clinical licensure as required by the Oregon contract (e.g., RN or behavioral health licensure such as LCSW, LPC, LCPC, LPA, PsyD, PhD)
Master's in physical or occupational therapy OR Master's in psychology, counseling, or social work OR Bachelor’s degree in nursing and licensed by the State of Oregon
3 years of clinical (direct patient care) experience; behavioral health preferred
Must reside in Oregon
Must have personal transportation
Ability to travel
Valid Driver License and Proof of Auto Insurance are required
Must maintain licensure eligibility for assigned state contract

Nice To Haves

Experience with Medicaid
Knowledge of the Oregon behavioral health system of care
2 years of utilization review or other medical management experience
2 years of full-time substance use disorder and/or behavioral health disorder experience
Clinical documentation review expertise, including use of the Oregon Health Plan Prioritized List of Health Services and InterQual
Strong organizational skills and ability to manage multiple tasks in a team environment
Excellent oral and written communication skills
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
Ability to document utilization review determinations accurately and timely in designated systems
Capability to provide clinical and utilization review subject matter expertise and respond to stakeholder questions or concerns

Responsibilities

Review clinical documentation to substantiate medical necessity and appropriateness for requested services
Perform initial and continued stay reviews using standardized, evidence-based criteria to ensure services align with individualized behavioral health needs
Apply clinical review criteria, organizational policies, guidelines, and screening tools to determine medical necessity of healthcare services
Document utilization review determinations accurately and timely in designated systems
Consult with physician or practitioner reviewers when cases do not meet clinical review criteria
Refer cases to other clinicians when appropriate
Provide clinical and utilization review subject matter expertise and respond to stakeholder questions or concerns
Support quality assurance activities, audits, and other program support as assigned
Provide guidance or oversight to non-clinical staff performing support activities, as appropriate
Perform other duties as assigned