[Hiring] Behavioral Health Case Manager/ Clinical Reviewer @COMAGINE HEALTH

Role Description

Are you passionate about improving access to behavioral health services in the community? Do you enjoy using your clinical expertise to evaluate needs, support care decisions, and help individuals receive the right services at the right time?

We're recruiting for multiple Behavioral Health / Clinical Reviewer roles across Oregon. Targeted areas include Portland metro, Eugene, and Salem. Candidates from elsewhere in Oregon are encouraged to apply.

In this role, you will:

• Review clinical documentation to determine medical necessity and appropriateness of services.
• Complete functional needs assessments that evaluate how mental health symptoms impact daily living.
• Support service coordination that connects children, youth, and adults to in-home and community-based care.
• Manage referrals, follow-ups, reviews, and assessments within an electronic medical record system.
• Apply evidence-based criteria to utilization management reviews.
• Document clinical determinations.
• Provide subject matter expertise to stakeholders.
• Support quality activities and audits.
• Travel for in-person assessments as needed across your assigned region.

If you are someone who demonstrates strong clinical judgment, builds trusting relationships with members and partners, and effectively manages a high-volume workload while meeting timelines, we encourage you to apply. If you bring a collaborative mindset, accountability in your work, curiosity to ask questions and learn, and comfort using technology to navigate systems and documentation, you will be well-positioned for success on this team.

This posting is for multiple openings across Oregon. Administrative tasks are conducted using company-issued equipment; travel to client sites in Oregon is required.

Qualifications

• QMHP OR current, active, unrestricted clinical licensure as required by the Oregon contract (e.g., RN or behavioral health licensure such as LCSW, LPC, LCPC, LPA, PsyD, PhD).
• Master's in physical or occupational therapy OR Master's in psychology, counseling, or social work OR Bachelor's degree in nursing and licensed by the State of Oregon.
• 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.

Requirements

• 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.

Competencies

• 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.

In this Role, You Will

• 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.

Work Environment

• Full-Time.
• 100% Remote (Oregon).
• Travel required.
• Reliable, secure internet connection required.
• Must maintain licensure eligibility for assigned state contract.

Physical Requirements & Work Environment

• This position is primarily remote and performed in a home-based setting, requiring reliable internet access and a workspace free from significant distractions.
• The role involves frequent use of computers, phones, and virtual communication tools.
• Employees must be able to sit for extended periods, communicate effectively.
• Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver’s license and meet the organization’s driving eligibility requirements.
• Occasional travel may be required for meetings, training, or other work-related events.
• Reasonable accommodations will be provided to enable individuals with disabilities to perform essential functions.