Payer Relations Clinician (LISWLPCC)

Location: Columbus OH (in person)
Department: Clinical Services
Reports To: Vice President of Clinical Services
Employment Type: Full-Time

Lighthouse Behavioral Health Solutions (LBHS) is committed to improving access to high-quality behavioral health care through clinical excellence evidence-based treatment and continuous performance improvement. We are seeking an experienced clinician to serve as our Payer Relations Clinician a key role responsible for representing the organization in payer clinical reviews supporting medical necessity determinations and identifying opportunities to improve authorization outcomes across our continuum of care.

The Payer Relations Clinicianserves as the organizations primary clinical representative for peer-to-peer reviews with Managed Care Organizations (MCOs) commercial payers Medicare Advantage plans and other insurance representatives.

This position reviews clinical documentation evaluates medical necessity and level-of-care determinations applies ASAM Criteria and other applicable clinical standards and presents clinical rationale supporting treatment recommendations and authorization requests. The Specialist works collaboratively with providers and clinical leadership to obtain supporting documentation and advocates for medically necessary care during payer reviews.

In addition to peer-to-peer representation this role is responsible for monitoring authorization approvals denials and peer-to-peer outcomes to identify trends support clinical performance improvement initiatives and strengthen organizational understanding of payer expectations.

This is a clinical utilization management position and does not include responsibility for authorization submission billing claims processing reimbursement or other Revenue Cycle Management functions.

• Serve as the organizations primary clinical representative during peer-to-peer reviews with payer representatives.
• Review clinical records and supporting documentation to prepare for peer-to-peer discussions.
• Evaluate clinical information to determine evidence supporting:
  • Medical necessity
  • Appropriate level of care
  • Continued stay criteria
  • Applicable payer requirements
• Apply ASAM Criteria and other relevant clinical standards when evaluating and presenting cases.
• Collaborate with direct service providers and clinical leadership to obtain additional information needed to support payer reviews.
• Present concise evidence-based clinical rationale supporting treatment recommendations and authorization requests.
• Respond effectively to clinical questions and concerns raised by payer representatives.
• Document peer-to-peer outcomes payer feedback and recommendations in accordance with organizational procedures.
• Communicate significant outcomes and trends to the Vice President of Clinical Services and relevant stakeholders.
• Participate in payer-requested chart reviews case consultations and other clinical review activities as needed.

• Track authorization approvals denials peer-to-peer reviews and review outcomes.
• Monitor whether payer determinations are upheld modified or overturned following peer-to-peer review.
• Analyze trends by payer service line level of care and treatment location.
• Identify recurring clinical factors associated with denials and adverse determinations.
• Maintain accurate data regarding peer-to-peer activity and effectiveness.
• Prepare routine reports regarding:
  • Authorization approval and denial trends
  • Peer-to-peer volume and outcomes
  • Common denial reasons
  • Medical necessity concerns
  • Documentation trends
  • Opportunities for clinical improvement
• Escalate significant or recurring concerns that warrant additional review or intervention.

• Analyze authorization and peer-to-peer outcomes to identify opportunities to improve clinical performance.
• Identify documentation and practice patterns that may negatively impact authorization decisions.
• Provide recommendations to clinical leadership related to:
  • Medical necessity documentation
  • ASAM application
  • Level-of-care decisions
  • Continued-stay justification
  • Clinical documentation standards
  • Responses to common payer concerns
• Provide targeted feedback to clinical leaders regarding identified trends.
• Assist in educating staff regarding recurring documentation and medical necessity concerns.
• Support development of clinical tools guidance documents and educational resources.
• Participate in utilization review meetings case consultations and quality improvement initiatives.

• Collaborate with Revenue Cycle Management (RCM) regarding denials and cases requiring peer-to-peer review.
• Communicate payer review outcomes that impact authorization decisions.
• Partner with providers and clinical leadership to gather necessary documentation and clinical information.
• Serve as an internal resource regarding payer expectations medical necessity determinations and denial trends.
• Participate in interdisciplinary meetings and special projects as requested.
• Perform other duties assigned by the Vice President of Clinical Services.

• Masters degree in Social Work Counseling Behavioral Health or related clinical field.
• Active and unrestricted Ohio independent behavioral health license:
  • Licensed Independent Social Worker (LISW)
  • Licensed Professional Clinical Counselor (LPCC)
• Minimum of three (3) years of behavioral health clinical experience.
• Strong knowledge of ASAM Criteria and level-of-care decision making.
• Ability to assess medical necessity and interpret complex clinical information.
• Strong clinical judgment and critical-thinking skills.
• Excellent written and verbal communication skills.
• Ability to present clinical information effectively in professional discussions with payer representatives.
• Experience collecting analyzing and reporting clinical performance data.
• Proficiency with electronic health record (EHR) systems.
• Ability to collaborate effectively with clinical teams and external stakeholders.
• Successful completion of required background screening compliance requirements and drug screening.

• LISW-S or LPCC-S designation.
• Experience conducting peer-to-peer reviews.
• Prior utilization management utilization review or managed care experience.
• Experience working with Medicaid Managed Care Organizations Medicare and commercial insurance plans.
• Knowledge of payer medical necessity criteria and authorization processes.
• Experience analyzing denial trends and utilization management outcomes.