Payer Relations Clinician (LISW/LPCC)

lighthousebehavioralhealthsolutions; Columbus (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

Lighthouse Behavioral Health Solutions (LBHS) is seeking a Payer Relations Clinician to represent the organization in payer clinical reviews and support medical necessity determinations. This full-time, in-person role is located in Columbus, OH within the Clinical Services team.

Responsibilities include peer-to-peer reviews, documenting outcomes, analyzing authorization trends, and collaborating with clinical leadership to improve approval rates and chart reviews across the continuum of care.

Qualifications

• Experience applying ASAM criteria in payer reviews.
• Ability to prepare evidence-based clinical rationales for authorizations.
• Strong collaboration with clinical leadership for documentation improvements.

Responsibilities

• Represent the organization during peer-to-peer payer reviews.
• Review clinical records to support medical necessity and level of care.
• Document outcomes, payer feedback, and recommendations per policy.
• Monitor authorization trends and escalate significant concerns.
• Prepare routine reports on denials, trends, and improvement opportunities.

Skills

ASAM Criteria

Payer Review

Medical Necessity

Job description

Payer Relations Clinician (LISW/LPCC)

Location: Columbus, OH (in person)

Department: Clinical Services

Reports To: Vice President of Clinical Services

Employment Type: Full-Time

About Lighthouse Behavioral Health Solutions

Lighthouse Behavioral Health Solutions (LBHS) offers a full continuum of care, including outpatient, intensive outpatient, partial hospitalization, residential treatment, psychiatric services, and medication‑assisted treatment. We take pride in creating a welcoming, compassionate environment where individuals feel supported. Our team believes in every client's ability to achieve recovery and rebuild meaningful, engaged lives in their communities.

Position Summary

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.

Essential Duties and Responsibilities

Clinical Review and Peer-to-Peer Representation

• Serve as the organization's 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.

Authorization and Outcome Monitoring

• 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.

Clinical Performance Improvement

• 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