Utilization Review Clinician

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.

• 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
  ** escalate
  * * delays that could affect admission timing.
• Document authorization numbers, approved dates and units, and payor contact information in AdvancedMD.

• Conduct concurrent and continued stay review for all clients in an active higher level of care, submitting within payor required time frames.
• 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.

• 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.

• 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 minimum information necessary to support the authorization decision, consistent with HIPAA, the Illinois Mental Health and Developmental Disabilities Confidentiality Act, and Clarity Clinic privacy policies.
• Maintain audit ready documentation of all authorization and review activity for Joint Commission Behavioral Health Care and Human Services review and payor audit.
• Report recurring denial reasons, payor delays, and documentation gaps to leadership monthly with supporting…