Payer-Facing Clinical Review Specialist

Lighthouse Behavioral Health Solutions; Columbus (OH); On-site; USD 85,000 - 125,000; Full time

Job summary

Lighthouse Behavioral Health Solutions in Columbus seeks a Peer-to-Peer Clinical Review Specialist to represent the organization in payer reviews, support medical necessity determinations, and improve authorization outcomes across the continuum of care.

You will review clinical documentation, apply ASAM criteria, coordinate with providers and leadership, monitor approvals and denials, and provide data-driven input to enhance utilization management while upholding compliance and quality standards.

Qualifications

• Master's degree in a clinical field and active Ohio license.
• Minimum 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.
• Excellent written and verbal communication skills.
• Experience with payer reviews and utilization management.

Responsibilities

• Represent the organization in peer-to-peer reviews with payer representatives.
• Review clinical records to prepare for payer discussions.
• Evaluate information to determine medical necessity and level of care.
• Apply ASAM Criteria and other standards when evaluating cases.
• Collaborate with providers and clinical leadership to obtain documentation.
• Present evidence-based clinical rationale for treatment and authorization.
• Monitor authorizations, denials, and peer-to-peer outcomes.
• Communicate outcomes to VP of Clinical Services.

Skills

Written and verbal communication

Clinical judgment

Medical necessity interpretation

EHR proficiency

Collaboration with clinical teams

Background screening & compliance

Education

Master's degree in Social Work, Counseling, Behavioral Health, or related field

LISW or LPCC license (Ohio)

LISW-S or LPCC-S designation (preferred)

Tools

EHR systems

Job description

Lighthouse Behavioral Health Solutions in Columbus seeks a Peer-to-Peer Clinical Review Specialist to represent the organization in payer reviews, support medical necessity determinations, and improve authorization outcomes across the continuum of care.

You will review clinical documentation, apply ASAM criteria, coordinate with providers and leadership, monitor approvals and denials, and provide data-driven input to enhance utilization management while upholding compliance and quality standards.