Clinical Reviewer - Eugene, Oregon

COMAGINE HEALTH•Eugene, OR

1d•$75,000 - $90,000•Remote

About The Position

This role focuses on improving access to behavioral health services by evaluating needs, supporting care decisions, and ensuring individuals receive appropriate services. The Clinical Reviewer will examine clinical documentation to determine medical necessity and appropriateness of services, conduct functional needs assessments to understand how mental health symptoms affect daily life, and assist in connecting individuals with in-home and community-based care. Responsibilities include managing referrals, follow-ups, reviews, and assessments within an electronic medical record system, applying evidence-based criteria for utilization management reviews, documenting clinical decisions, providing expertise to stakeholders, and supporting quality activities and audits. Travel for in-person assessments within the assigned region is also required. The ideal candidate possesses strong clinical judgment, builds trusting relationships, manages a high-volume workload effectively, has a collaborative mindset, demonstrates accountability and curiosity, and is comfortable 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
Must 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
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

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
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 guidance or oversight to non-clinical staff performing support activities, as appropriate
Perform other duties as assigned