Utilization Review Clinician

Clarity Clinic•Chicago, IL

6d•Onsite

About The Position

The Utilization Review Clinician is responsible for reviewing clinical documentation against payor medical necessity criteria, preparing and submitting prior authorization and precertification requests, and tracking pending determinations. This role also involves concurrent review and continued stay reviews, communicating with treatment teams, and conducting peer-to-peer reviews and appeals. Additionally, the clinician will ensure compliance with documentation standards, HIPAA, and other relevant regulations, report recurring denial reasons to leadership, and provide guidance to staff on documentation best practices. The role requires a commitment to equity, trauma-informed care, and high-quality, accessible behavioral health services.

Requirements

Active, unrestricted Illinois license: LCSW, LCPC, LMFT, or RN.
2 or more years of post licensure clinical experience in behavioral health, mental health, or substance use treatment.
Working knowledge of behavioral health levels of care, including PHP, IOP, and outpatient services.
Working knowledge of payor medical necessity criteria such as LOCUS, CALOCUS, MCG, InterQual, or payor specific criteria.
Working knowledge of HIPAA and Illinois MHDDCA confidentiality requirements as applied to disclosures to payors.
Proficiency in Microsoft 365, including Outlook, Word, Excel, and Teams.
Ability to manage multiple concurrent reviews and competing payor deadlines, and to work additional hours when a deadline requires it.

Nice To Haves

Prior utilization review, utilization management, or managed care experience, on either the provider or payor side.
Experience conducting peer to peer review with payor medical reviewers.
Experience preparing first level appeals.
Experience in AdvancedMD.
Experience with TMS and esketamine medical necessity criteria, including documentation of failed medication trials.
Commitment to equity, trauma informed care, and high quality, accessible behavioral health services.

Responsibilities

Review clinical documentation against payor medical necessity criteria before submission, identify gaps, and request the specific additions needed from the treating clinician.
Prepare and submit prior authorization and precertification requests for admission to PHP, IOP, TMS, Esketamine, and neuropsychological testing.
Track pending determinations, follow up daily until a decision is issued, and escalate delays that could affect admission timing.
Document authorization numbers, approved dates and units, and payor contact information in AdvancedMD.
Conduct concurrent and continued stay review for all clients in an active higher level of care, submitting within payor required timeframes.
Interpret progress notes, treatment plans, and assessments authored by the treating clinician to construct the medical necessity case for continued treatment.
Monitor authorization expiration dates and initiate renewal review in advance to prevent lapses in authorized days.
Communicate level of care changes, discharge planning needs, and authorization status to the treatment team, Intake, and Billing.
Conduct peer to peer review with payor medical reviewers where the payor accepts the incumbent's license level.
Schedule and brief clinicians for peer-to-peer calls when required by the payor, focusing on criteria, dates, and supporting documentation.
Prepare and submit first level appeals following an adverse determination, within the payor's appeal window.
Log every adverse determination on the day it is received and notify the treatment team and Billing.
Summarize and cite the treating clinician's record when communicating with payors, without authoring clinical findings or altering the clinical record.
Disclose only the minimum information necessary to support the authorization decision, consistent with HIPAA, the Illinois Mental Health and Developmental Disabilities Confidentiality Act, and Clarity Clinic privacy policies.
Maintain audit-ready documentation of all authorization and review activity for Joint Commission Behavioral Health Care and Human Services review and payor audit.
Report recurring denial reasons, payor delays, and documentation gaps to leadership monthly with supporting data, and recommend corrective action.
Provide guidance and training to Intake and clinical staff on documentation that supports medical necessity.
Review the accuracy of benefit verification completed by Intake staff and escalate coverage or financial risk.
Perform other duties as assigned by their supervisor.