Utilization Review Clinician

Clarity Clinic • Chicago, IL

5d • Onsite

About The Position

The Utilization Review Clinician is responsible for managing prior authorizations, concurrent reviews, continued stay reviews, and appeals for various behavioral health services. This role involves reviewing clinical documentation against payor medical necessity criteria, identifying documentation gaps, and requesting necessary additions from treating clinicians. The clinician will prepare and submit authorization requests, track pending determinations, and escalate delays. They will also conduct concurrent and continued stay reviews, interpret clinical records to support medical necessity, and monitor authorization expiration dates. Communication with the treatment team, Intake, and Billing regarding authorization status and level of care changes is crucial. For peer-to-peer reviews, the clinician will represent the case or brief the prescribing clinician. They will also prepare and submit first-level appeals following adverse determinations and maintain audit-ready documentation. Monthly reporting on denial reasons, payor delays, and documentation gaps to leadership is required, along with providing guidance to staff on documentation best practices. The role also includes reviewing the accuracy of benefit verification and escalating coverage or financial risks.

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.
• Ability 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 for prior authorization.
• Identify documentation gaps and request specific additions from the treating clinician.
• Prepare and submit prior authorization and precertification requests for various services (PHP, IOP, TMS, Esketamine, neuropsychological testing).
• Track pending determinations, follow up daily, and escalate delays that could affect admission timing.
• Document authorization numbers, approved dates and units, and payor contact information.
• Conduct concurrent and continued stay review for all clients in an active higher level of care.
• Interpret progress notes, treatment plans, and assessments to construct the medical necessity case for continued treatment.
• Monitor authorization expiration dates and initiate renewal review in advance.
• 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 accepted.
• Schedule and brief clinicians for peer-to-peer calls when required by the payor.
• Prepare and submit first-level appeals following an adverse determination.
• Log every adverse determination and notify the treatment team and Billing.
• Summarize and cite the treating clinician's record when communicating with payors.
• Disclose only the minimum information necessary to support the authorization decision, consistent with HIPAA and relevant privacy acts.
• Maintain audit-ready documentation of all authorization and review activity.
• Report recurring denial reasons, payor delays, and documentation gaps to leadership monthly with supporting data and recommendations.
• 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 risks.

Benefits

• Clarity Clinic is an equal opportunity employer.
• Encourages applications from minorities, LGBTQ+ individuals, candidates of all ages, and nontraditional backgrounds.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed