Utilization Review Clinician

Clarity Clinic, PLLC; Chicago (IL); On-site; USD 70,000 - 100,000; Full time

Job summary

Clarity Clinic, PLLC in Chicago, Illinois, seeks an Utilization Review Clinician to own the clinical utilization review function, including prior authorization, concurrent and continued stay reviews, peer to peer reviews, and first level appeals across all lines of care. This licensed, non-treating role requires applying payor criteria to the treating record and ensuring timely authorizations.

The successful candidate will coordinate with the treatment team, intake, and billing, and perform

Responsibilities

• Review documentation against payor medical necessity criteria and identify gaps.
• Prepare and submit preauthorizations for admission to PHP, IOP, TMS, Esketamine, and neuropsychological testing.
• Track determinations and follow up daily until a decision is issued.
• Monitor authorization expirations and initiate renewal reviews in advance.
• Coordinate peer-to-peer reviews and first-level appeals.
• Summarize and cite records when communicating with payors; do not alter the clinical record.

Tools

AdvancedMD

Job description

Utilization Review Clinician

Clarity Clinic, PLLC Chicago, Illinois, United States

About this position

About Clarity Clinic

Clarity Clinic is an interdisciplinary private practice bringing together Psychiatrists, Advanced Practice Providers (PAs, NPs), Psychologists, and Therapists. Our mission is to guide the whole person toward clarity and mental wellness through exceptional, holistic care. We offer a broad range of specialties and treatment approaches — including medication management, psychological assessment, and psychotherapy — to support people wherever they are in life. Through this multidisciplinary model, we're redefining what accessible, comprehensive mental health care looks like.

The Utilization Review Clinician owns the clinical utilization review function for Clarity Clinic, covering prior authorization for admission, concurrent and continued stay review, peer to peer review, and first level appeals across all higher level of care and specialty service lines. This is a licensed, non-treating clinical role. The incumbent applies clinical training to interpret the treatment record against payor medical necessity criteria and to represent Clarity Clinic's clinical case to payor reviewers.

This position is the primary clinical liaison with insurance payors during the pre-admission and active treatment phases. The Clinician ensures that authorizations are obtained and maintained in accordance with payor and regulatory requirements, and that documentation submitted to payors accurately reflects the treating clinician's record. The role operates against externally set payor deadlines, so it requires consistent responsiveness by phone and payor portal and flexibility to work additional hours when a determination deadline requires it.

Duties / Responsibilities:

Prior Authorization for Admission:

Review clinical documentation against payor medical necessity criteria before submission, identify gaps, and request the specific additions needed from the treating clinician. Prepare and submit prior authorization and precertification requests for admission to PHP, IOP, TMS, Esketamine, and neuropsychological testing. Track pending determinations, follow up daily until a decision is issued, and elevate delays that could affect admission timing. Document authorization numbers, approved dates and units, and payor contact information in AdvancedMD.

Concurrent Review and Continued Stay:

Conduct concurrent and continued stay review for all clients in an active higher level of care, submitting within payor required timeframes. Interpret progress notes, treatment plans, and assessments authored by the treating clinician to construct the medical necessity case for continued treatment. Monitor authorization expiration dates and initiate renewal review in advance to prevent lapses in authorized days. Communicate level of care changes, discharge planning needs, and authorization status to the treatment team, Intake, and Billing.

Peer to Peer and Appeals:

Conduct peer to peer review with payor medical reviewers where the payor accepts the incumbent's license level. Where a payor requires a prescriber or the treating provider, schedule the call and brief that clinician on the criteria at issue, the dates in question, and the supporting documentation. Prepare and submit first level appeals following an adverse determination, within the payor's appeal window. Log every adverse determination on the day it is received and notify the treatment team and Billing.

Compliance, Documentation, and Reporting:

Summarize and cite the treating clinician's record when communicating with payors. The Utilization Review Clinician does not author clinical findings, diagnoses, or assessments that the incumbent did not personally form, and does not alter the clinical record. Disclose only the