Payer Relations Clinician (LISW/LPCC)

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.

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) 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. 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.

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 dete