CAP Clinical POC Reviewer

Acentra Health, LLC; United States; Sur place; USD 39 000 - 54 000; Plein temps

Résumé du poste

Acentra Health is seeking a CAP Clinical POC Reviewer to join our team. The role uses clinical expertise to review HCBS waiver requests, Plans of Care, reassessments, medical records, and related documents against regulatory standards and program rules.

You will ensure accurate determinations and timely communications. You will collaborate with leadership and stakeholders, maintain up-to-date knowledge of review processes, support quality monitoring, and contribute to process improvements.

Qualifications

• Active, unrestricted RN license.
• Minimum of two years of relevant clinical services experience.
• Knowledge of medical records, medical terminology, and disease processes.
• Excellent written and verbal communication skills.
• Ability to work independently and manage multiple projects in a fast-paced environment.

Responsabilités

• Reviews HCBS waiver requests, Plans of Care, reassessments, and medical records against clinical criteria and policies.
• Ensures timely, accurate, and compliant determinations and writes denial/minor-communications as needed.
• Maintains workload and meets productivity and quality standards.
• Performs second-level reviews and supports quality monitoring activities.
• Acts as a liaison to internal and external stakeholders to resolve issues and support customer service.

Connaissances

Clinical review

Regulatory knowledge

Communication skills

Formation

Registered Nurse license (RN)

Outils

Microsoft Office

Description du poste

Company Overview

Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

At Acentra Health, we embrace emerging technologies, including artificial intelligence and advanced analytics that can be utilized to improve processes, enhance decision-making, and drive better health outcomes. We value professionals who are curious about new technologies and motivated to use innovative tools to increase efficiency, quality, and impact in their roles.

Job Summary and Responsibilities

Acentra Health is looking for a CAP Clinical POC Reviewer to join our growing team.

Job Summary:

• The position utilizes clinical expertise to review, evaluate, and process Home and Community-Based Services (HCBS) waiver requests, Plans of Care (POC), reassessments, medical records, and related documentation against applicable clinical criteria, Medicaid policies, waiver requirements, contractual obligations, and program standards.

Responsibilities:

• Conducts clinical reviews of service plans/Plans of Care (POC) and other assigned review types in accordance with contract requirements, regulatory standards, and clinical guidelines.
• Ensures timely, accurate, and compliant case determinations, including the preparation of denial determinations and related correspondence when applicable.
• Meets established productivity, quality, and turnaround time expectations.
• Performs second-level reviews and supports quality monitoring activities as assigned.
• Monitors and prioritizes workload to ensure service levels and departmental objectives are met.
• Serves as a clinical resource and liaison to internal and external stakeholders, supporting issue resolution and customer service needs.
• Maintains current knowledge of review processes, clinical practices, regulatory requirements, and program updates through ongoing training and development.
• Collaborates with leadership and team members to support operational goals, process improvement initiatives, and continuity of operations.
• Provides cross-training and cross-coverage across review functions, including support for other review queues, quality activities, and staff education as needed.
• Builds and maintains positive, professional relationships with internal and external customers.
• Complies with all corporate policies, including HIPAA Privacy and Security requirements.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Note: The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.

Qualifications

Required Qualifications

• Active, unrestricted Registered Nurse license in a Compact state.
• Minimum of two years of relevant experience in clinical services, case management, utilization management, healthcare, critical thinking, legal requirements, or healthcare policies and procedures.
• Demonstrated knowledge and skills equivalent to advanced-level practice.
• Knowledge of medical records, medical terminology, and disease processes.
• Excellent written and verbal communication skills.
• Ability to work independently, prioritize tasks, and manage multiple projects simultaneously in a fast-paced environment.

Preferred Qualifications

• Master's Degree from an accredited college or university in a related field.
• Experience working in a regulated environment.
• Knowledge of and experience reviewing and participating in legal claims or policies from a clinical perspective.
• Proficiency with Microsoft Office applications and other systems required to perform assigned responsibilities.
• Ability to establish and maintain positive working relationships with internal and external stakeholders.
• Ability to communicate concerns and recommendations professionally.
• Ability to collaborate effectively in a team environment.

Why us?

We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.

We do this through our people.

You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.

Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

Experience in Lieu of Degree

For non-clinical roles, or when not required by the contract specifically, the Company acknowledges that practical, hands-on experience can provide skills and competencies equivalent to formal education. As such, in cases where a Bachelor's degree may be required, the Company will accept a minimum of six (6) years of directly relevant professional experience in lieu of a degree. In instances where the candidate has an Associate's degree, the Company will accept a minimum of three (3) years of directly relevant professional experience in lieu of the Bachelor's degree.

We are committed to providing a secure and positive hiring experience. Depending on the role, interviews may be conducted virtually, in person, or through a combination of both. As part of our recruitment process, candidates may be asked to participate in identity verification measures to help ensure the integrity of the hiring process.

EEO AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

Compensation

The pay range for this position is listed below.

“Based on our compensation philosophy, an applicant’s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.”

Pay Range

USD $28.37 - USD $39.19 /Hr.