Medical Reviewer Jobs in Remote, OR (NOW HIRING)

Behavioral Health Utilization Management 

• Evaluate behavioral health and substance use disorder services to determine medical necessity, level of care, benefit eligibility, and compliance with established clinical guidelines. 

• Review behavioral health, Health-Related Social Needs (HRSN), and Flexible Services requests for appropriateness and coverage determination. 

• Conduct prospective, concurrent, and retrospective reviews, including inpatient behavioral health reviews, discharge planning, and transitions of care. 

• Apply clinical judgment and evidence-based criteria to make utilization decisions and identify cases requiring Medical Director review. 

• Request and evaluate additional clinical information from providers and members to support timely and accurate determinations. 

• Complete appeal reviews in collaboration with the Grievance and Appeals team. 

Care Coordination and Member Support 

• Collaborate with care management teams, providers, and internal departments to support integrated behavioral and physical healthcare services. 

• Advocate for members by promoting access to timely, effective care in the least restrictive and most appropriate setting. 

• Support transitions from inpatient, residential, acute care, and Oregon State Hospital settings to community-based services. 

• Identify barriers to care and support solutions that promote continuity of services and improved outcomes. 

Provider and Community Engagement 

• Partner with behavioral health providers and healthcare teams regarding treatment plans, level of care, and utilization management processes. 

• Provide education and guidance to providers, members, and families regarding behavioral health benefits, services, and available resources. 

• Develop and maintain effective relationships with community providers and organizations. 

Compliance and Quality Improvement 

• Maintain compliance with Umpqua Health policies, contractual requirements, and applicable state and federal regulations, including Oregon Administrative Rules (OAR), Oregon Health Plan (OHP), Medicare guidelines, and grievance and appeal requirements. 

• Maintain accurate, timely, and comprehensive clinical documentation in accordance with regulatory and organizational standards. 

• Conduct quality reviews and audits to identify opportunities for process improvement. 

• Meet departmental expectations for productivity, accuracy, quality, and turnaround times. 

Additional Responsibilities 

• Collaborate with Third-Party Recovery and Customer Care teams regarding coverage, eligibility, and coordination of benefits. 

• Participate in clinical rounds, case reviews, and interdisciplinary discussions. 

• Provide training and support to new employees and cross-functional teams as needed. 

• Perform other duties and responsibilities as assigned. 

• Working with a variety of personalities, maintaining a consistent and fair communication style.
• Satisfying the needs of a fast-paced and challenging company.

• Current Oregon license to practice independently as one of the following: 

• Licensed Clinical Social Worker (LCSW) 

• Licensed Professional Counselor (LPC) 

• Licensed Marriage and Family Therapist (LMFT) 

• Registered Nurse (RN) with Behavioral Health certification (e.g., PMH-BC) 

• Certified Alcohol and Drug Counselor (CADC I) certification, at minimum. 

• Master's degree in Social Work, Counseling, Psychology, Nursing, or a related behavioral health field. 

• Two (2) to four (4) years of behavioral health, substance use disorder, addiction treatment, or care management experience. 

• Clinical knowledge of mental health and substance use treatment with the ability to assess treatment plans and medical necessity. 

• Eligible to participate in federal healthcare programs (no Medicare/Medicaid suspension, exclusion, or debarment). 

• Proficiency with Microsoft Office and standard computer systems. 

• Valid driver’s license and proof of current automobile insurance. 

• Must not be suspended, excluded, or debarred from participation in federal health care programs (e.g., Medicare/Medicaid). 

• Experience in Behavioral Health Utilization Management/Utilization Review, Case Management, or Managed Care. 

• Experience reviewing behavioral health services, including prior authorization, concurrent review, discharge planning, and care coordination for mental health and substance use disorders across inpatient, residential, partial hospitalization, or intensive outpatient (IOP) settings. 

• Knowledge of health plan benefits, community resources, electronic health records, and quality improvement processes. 

• Strong analytical, critical thinking, problem-solving, and organizational skills with the ability to manage multiple priorities independently in a fast-paced environment. 

• Demonstrated ability to collaborate effectively with providers, multidisciplinary teams, and diverse communities while maintaining cultural awareness, professionalism, confidentiality, and regulatory compliance. 

• Maintains current clinical knowledge and applicable certifications. 

• Experience evaluating the impact of work across diverse communities, including communities of color, in technical analysis. 

• Experience working in diverse team environments and across varying communication styles. 

• Bilingual translation skills are a plus. 

• Salary is dependent on skills, experience, and education
• Generous benefits package including vacation PTO, sick leave, federal holidays, and birthday leave
• Medical, dental, and vision insurance
• 401(k) with company match (fully vested immediately)
• Company-sponsored life insurance and additional benefits
• Fitness reimbursement program
• Tuition reimbursement and more

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