Clinical Reviewer - Eugene, Oregon

COMAGINE HEALTH•Eugene, OR

7d•$75,000 - $90,000•Remote

About The Position

Comagine Health is a national, mission-driven, nonprofit organization that has engaged in health care quality consulting and quality improvement services for more than 50 years. We are leaders in assisting front-line providers and engaging health care partners to improve care delivery and patient outcomes. Our talented remote workforce spans the country and plays a vital role in our success. We offer opportunities to make a difference from anywhere in the U.S. and enjoy better work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs. We believe in an environment that allows you to thrive both personally and professionally. This role involves reviewing clinical documentation to determine medical necessity and appropriateness of services, completing functional needs assessments, and supporting service coordination. You will manage referrals, follow-ups, reviews, and assessments within an electronic medical record system; apply evidence-based criteria to utilization management reviews; document clinical determinations; provide subject matter expertise to stakeholders; support quality activities and audits; and travel for in-person assessments as needed across your assigned region. We are looking for individuals who demonstrate strong clinical judgment, build trusting relationships, effectively manage a high-volume workload, possess a collaborative mindset, accountability, curiosity, and comfort using technology.

Requirements

Current, active, unrestricted clinical licensure as required by the Oregon contract (e.g., behavioral health licensure such as LCSW, LPC, LCPC)
3 years of clinical (direct patient care) experience; behavioral health preferred
Candidates must reside in Oregon
Have personal transportation
Ability to travel
Valid Driver License and Proof of Auto Insurance are required
Reliable, secure internet connection required
Must maintain licensure eligibility for assigned state contract
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

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

Responsibilities

Review clinical documentation to determine medical necessity and appropriateness of services
Complete functional needs assessments that evaluate how mental health symptoms impact daily living
Support service coordination that connects children, youth, and adults to in-home and community-based care
Manage referrals, follow-ups, reviews, and assessments within an electronic medical record system
Apply evidence-based criteria to utilization management reviews
Document clinical determinations
Provide subject matter expertise to stakeholders
Support quality activities and audits
Travel for in-person assessments as needed across your assigned region
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