Clinical Reviewer - LCSW, LPC, LCPC

Comagine Health is a national, mission-driven nonprofit organization focused on health care quality consulting and quality improvement. The Clinical Reviewer will evaluate behavioral health documentation and medical necessity, perform functional needs and utilization reviews, coordinate referrals and services, document clinical determinations, and support stakeholders, quality activities, and audits while traveling for assessments as needed.

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

Preferred

• 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
• Medicaid Experience
• Oregon Behavioral Health System
• Utilization Review
• Medical Management
• Substance Use Disorder Experience
• Behavioral Health Disorder Experience

Benefits

• 100% remote work based in Oregon
• An annual stipend to enhance your workspace
• Medical, dental and vision insurance
• Paid time off for vacation, illness, and volunteering
• Retirement savings plan with employer contribution
• Adoption financial assistance
• Paid parental leave

Company

• Nonprofit health care consulting firm
• Seattle, Washington, USA
• https://comagine.org/
• Founded in 1973
• 201-500 employees

Qualifications

• 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, and 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
• 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

Required skills

• Behavioral Health, Clinical Documentation Review, Clinical Licensure, Clinical Licensure LCPC, Clinical Licensure LCSW, Clinical Licensure LPC, InterQual, Medicaid, Medical Necessity Determination, Oregon Health Plan Prioritized List of Health Services, Substance Use Disorder, Utilization Review

Preferred skills

• Experience with Medicaid, Knowledge of the Oregon behavioral health system of care

Experience

• 3+ years