Payer Relations Clinician (LISW/LPCC)

We need to output HTML fragment with sections using

for headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We must not repeat job title as heading. Must not include Job ID etc. Must preserve all substantive info, not invent or summarize away detail. Remove boilerplate: EEO, equal opportunity, etc. Also remove duplicated lines, navigation, cookie, legal, scam-warning, application instructions. We need to extract content. Let's parse the posting: - Intro paragraph about LBHS: "Lighthouse Behavioral Health Solutions (LBHS) offers a full continuum of care... We take pride...". This is about the organization, could be part of "About the role"? Actually "About Lighthouse Behavioral Health Solutions" appears later. The intro could be considered "About the role"? But we have a section "About the role". The posting includes "About Lighthouse Behavioral Health Solutions" after the location line. That is about the organization. We can put that under "About the role" maybe? Or we could have a separate "About the organization" but not in allowed headings. The allowed headings list includes About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. So we need to map content accordingly. We have: - Position Summary: description of role. That could go under "About the role". - Essential Duties And Responsibilities: list of duties. That goes under "Responsibilities". - Required Qualifications: list of qualifications. That goes under "Qualifications". Also there is "Preferred Qualifications". Could be part of Qualifications or separate? We could combine both under Qualifications, but we need to avoid filler. We could have a subsection? Not allowed. Probably just include both required and preferred under Qualifications. - Skills: maybe we can extract skills from responsibilities and qualifications: strong knowledge of ASAM Criteria, ability to assess medical necessity, strong clinical judgment, critical-thinking, excellent written/verbal communication, ability to present clinical info, experience collecting/analyzing/reporting clinical performance data, proficiency with EHR, ability to collaborate, etc. Could be a Skills section. - Benefits: The posting includes "Our benefits package includes paid time off (PTO and sick time), paid holidays, medical/dental/vision, 401(k), life insurance, paid continuing education with supervision, parental leave, and eligibility for loan forgiveness programs." That's benefits. So we can include Benefits section. - Pay: Not mentioned. No pay info. So we should NOT include Pay section. - Schedule: Not mentioned. No schedule info. So we should NOT include Schedule section. We must not include EEO boilerplate. Remove duplicated lines. Also remove "Equal Employment Opportunity" paragraphs. We must preserve all substantive information. So we need to include the intro about LBHS offering continuum of care, welcoming environment, etc. That is substantive. Where to place? Could be under About the role (maybe as description of organization). Or we could create a separate section but not allowed. So we put it under About the role. We also have "Position Summary" which is also about role. We'll combine. We need to use

for section headings. Use

• for any list of duties/requirements/benefits, and

  for prose. We must not repeat the job title as a heading. The job title is "Payer Relations Clinician (LISW/LPCC)". Not to be used as heading. We must not put Job ID/requisition numbers as headings. We must output ONLY the HTML fragment. Let's structure:

  About the role

  ... (intro about LBHS and position summary)

  Responsibilities

  • ... each duty

  Qualifications

  • ... required qualifications
  • ... preferred qualifications (maybe separate bullet)

  Skills

  • ... skills extracted

  Benefits

  • ... benefits list
  We must ensure we don't include filler like "commensurate with experience". Not present. We need to preserve all substantive info: Let's extract. Intro about LBHS: "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." Then later: "About Lighthouse Behavioral Health Solutions 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." We can combine these. Position Summary: "The Payer Relations Clinician serves as the organization's 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." We'll put that in About the role. Now Responsibilities: The "Essential Duties And Responsibilities" section has sub-sections: Clinical Review and Peer-to-Peer Representation, Authorization and Outcome Monitoring, Clinical Performance Improvement, Collaboration and Clinical Consultation. We need to extract each duty as bullet points. Let's list them: 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 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. Collaboration and Clinical Consultation: - 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. We need to preserve all substantive info; we can keep sub-bullets as nested lists? The instruction: Use
  • for any list of duties/requirements/benefits. It doesn't forbid nested lists, but we can keep flat list with each duty as a bullet; sub-points could be separate bullets. That's okay. Now Qualifications: Required Qualifications: - Master's degree in Social Work, Counseling, Behavioral Health, or related clinical field. - Active and unrestricted Ohio independent behavioral health license: Licensed Independent Social Worker (LISW) or 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. Preferred Qualifications: - 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. We can combine required and preferred into one list, maybe separate with a note? But we can just list all; it's okay. Skills: We can extract skills from responsibilities and qualifications: - Clinical documentation review - Medical necessity evaluation - Level-of-care determination - ASAM Criteria application - Peer-to-peer representation - Data analysis and reporting - Trend analysis - Communication with payer representatives - Collaboration with providers and leadership - EHR proficiency - Critical thinking and clinical judgment - Written and verbal communication - Presentation of clinical rationale - Documentation and reporting - Performance improvement initiatives - Education and training staff - Development of clinical tools and guidance - Interdisciplinary collaboration We'll list as bullet points. Benefits: - Paid time off (PTO and sick time) - Paid holidays - Medical/dental/vision - 401(k) - Life insurance - Paid continuing education with supervision - Parental leave - Eligibility for loan forgiveness programs We must not include EEO boilerplate. Remove duplicated lines: The posting had repeated EEO statements; we will omit. Now ensure we don't include any filler like "commensurate with experience". Not present. Now produce HTML. We need to wrap each section with

    heading and then content. For About the role: we can have a

    containing the combined intro and position summary. Let