Clinical Reviewer - Portland, Oregon

COMAGINE HEALTH• OR, US, OR

1d•$75,000 - $90,000•Remote

About The Position

In this role, you will review clinical documentation to determine medical necessity and appropriateness of services, complete functional needs assessments that evaluate how mental health symptoms impact daily living, and support service coordination that connects children, youth, and adults to in-home and community-based care. 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. If you are someone who demonstrates strong clinical judgment, builds trusting relationships with members and partners, and effectively manages a high-volume workload while meeting timelines, we encourage you to apply. If you bring a collaborative mindset, accountability in your work, curiosity to ask questions and learn, and comfort using technology to navigate systems and documentation, you will be well-positioned for success on this team. This is a remote position based in Oregon and travel is required.

Requirements

Current, active, unrestricted clinical licensure as required by the Oregon contract (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
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

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

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