Utilization Review Clinician

Duties / Responsibilities: Prior Authorization for Admission: 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. Concurrent Review and Continued Stay: 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. Peer to Peer and Appeals: Conduct peer to peer review with payor medical reviewers where the payor accepts the incumbent's license level. Where a payor requires a prescriber or the treating provider, schedule the call and brief that clinician on the criteria at issue, the dates in question, and the 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. Compliance, Documentation, and Reporting: Summarize and cite the treating clinician's record when communicating with payors. The Utilization Review Clinician does not author clinical findings, diagnoses, or assessments that the incumbent did not personally form, and does not alter 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. Routine verification of benefits remains with the Intake team. Qualifications and Minimum Requirements: Required: 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. Preferred: 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. Role Competencies: Medical Necessity Judgment: Reads the treatment record against the applicable payor criteria, identifies what is missing, and requests the specific clinical additions needed rather than submitting an incomplete record. Concurrent Review Timeliness: Submits every continued stay review within the payor required timeframe and maintains no lapse in authorized days for clients in an active level of care. Peer to Peer Advocacy: Presents the clinical case to payor reviewers accurately and persuasively, and when the call belongs to a prescriber, briefs that clinician in advance on the criteria, dates, and documentation at issue. Appeal Execution: Assembles and files first level appeals within the payor's appeal window, with the clinical record cited to the specific criteria in dispute. Record Integrity: Summarizes and cites the treating clinician's documentation without authoring clinical findings the incumbent did not form, and never alters the clinical record to support an authorization. Confidentiality and Minimum Necessary: Limits payor disclosures to the information required for the authorization decision and applies HIPAA and Illinois MHDDCA standards to every release of clinical information. Cross Functional Coordination: Communicates level of care changes, authorization status, and discharge planning needs to Intake, the clinical team, and Billing without waiting to be asked. Audit Readiness: Maintains documentation of authorization and review activity that can be produced for Joint Commission or payor audit without reconstruction. Staff Development: Coaches Intake and clinical staff on documentation practices that support medical necessity, using patterns identified in actual determinations. Trend Identification and Escalation: Reports recurring denial reasons, payor delays, and documentation gaps to leadership monthly with supporting data and a recommended correction. Physical Requirements: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear or effectively communicate with others. The employee is frequently required to sit and use a keyboard and telephone for extended periods, and to view a computer screen with close vision and the ability to adjust focus. The employee is occasionally required to stand, walk, stoop, kneel, or crouch. The employee must occasionally lift and/or move up to 25 pounds. Other duties: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Incumbents will follow any other instructions and perform related duties, as assigned by their supervisor. We celebrate diversity when it comes to all backgrounds and identities, and we encourage applications from minorities, LGBTQ+ individuals, candidates of all ages, and nontraditional backgrounds. Clarity Clinic an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics. Please stay alert to protect yourself from sophisticated job scams during the recruiting process. Only emails that come from are legitimate recruiting messages. Our HR Team will not send emails from other domains, or message you using WhatsApp or text messaging. We conduct all interviews by phone or video, and we will never ask you for money or to download software either during the interview process, credentialing or during our onboarding process. More tips from the FTC to avoid job scams: About Clarity Clinic Clarity Clinic is an interdisciplinary private practice bringing together Psychiatrists, Advanced Practice Providers (PAs, NPs), Psychologists, and Therapists. Our mission is to guide the whole person toward clarity and mental wellness through exceptional, holistic care. We offer a broad range of specialties and treatment approaches — including medication management, psychological assessment, and psychotherapy — to support people wherever they are in life. Through this multidisciplinary model, we're redefining what accessible, comprehensive mental health care looks like. The Utilization Review Clinician owns the clinical utilization review function for Clarity Clinic, covering prior authorization for admission, concurrent and continued stay review, peer to peer review, and first level appeals across all higher level of care and specialty service lines. This is a licensed, non-treating clinical role. The incumbent applies clinical training to interpret the treatment record against payor medical necessity criteria and to represent Clarity Clinic's clinical case to payor reviewers. This position is the primary clinical liaison with insurance payors during the pre-admission and active treatment phases. The Clinician ensures that authorizations are obtained and maintained in accordance with payor and regulatory requirements, and that documentation submitted to payors accurately reflects the treating clinician's record. The role operates against externally set payor deadlines, so it requires consistent responsiveness by phone and payor portal and flexibility to work additional hours when a determination deadline requires it.