Clinical Review Advisor

Acentra Health, LLC; United States; Remote; USD 92,000 - 105,000; Full time

Benefits offered by this job

Comprehensive health plans

Paid time off

Retirement savings

Job summary

Acentra Health, LLC is seeking a Clinical Review Advisor to join our team. The role focuses on reviewing medical records, preparing cases for physician review, and performing related duties for selected cases with attention to MCC policies.

The position is remote within the United States with standard Central Time business hours. The first day requires travel to the Nashville, TN office, and coordination with Tennessee Medicaid departments is routine.

Qualifications

• Active, unrestricted RN license from the state of residence or compact multi-state.
• Bachelor's degree in a related field as per state requirements.
• 2+ years of recent nursing or medical records experience.
• Must have a dedicated home office and reliable internet access for secure viewing of PHI.

Responsibilities

• Prepare medically necessity reviews within established timeframes and contractual guidelines, including formatting, documentation of appealed services, and citation of applicable Medicaid rules.
• Communicate with external customers to provide information relevant to the review process and results.
• Review requests for inconsistencies or missing information and coordinate with staff and Tennessee Medicaid departments.
• Monitor the Outstanding MNR Report to track deliverables and priorities.
• Coordinate MCC witnesses with the Office of Fair Hearings, including prehearing conferences and scheduling.
• Edit reviews and collaborate with Physicians to address quality issues and improvements.
• Collaborate with staff and Medical Director to implement process improvements.
• Assist Medical Director with communications to Medicaid staff regarding quality concerns.
• Support training for Reviewers and quarterly quality assurance activities.
• Adhere to corporate policies including HIPAA Privacy and Security Rules.

Skills

RN license

Home office setup

Education

Bachelor's degree

Tools

Microsoft Office

Job description

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 Clinical Review Advisor to join our growing team.

Job Summary:

The purpose of this position is to review medical records, prepare cases for physician review, and perform related activities for selected cases on a timely, accurate, and efficient basis. The selected candidate will prepare reports and other documentation for medical necessity reviews with special attention to State and managed care contractor (MCC) policies.

The position is remote within the U.S. and follows regular Monday through Friday business hours. The team operates on Central Time, with flexibility for candidates in Eastern, Central, or Mountain Time. Due to tight turnaround times and deadlines, Pacific Time schedules cannot be accommodated. The first day requires travel to the Nashville, TN office.

Responsibilities:

• Prepare medically necessity reviews within established timeframes and contractual guidelines, including required formatting and grammar, documentation of appealed services, citation of applicable State Medicaid rules, and application of appropriate Office Reference Manual and/or Medicaid Clinical Criteria based on the appealed service and enrollee population.
• Communicate verbally and in writing with external customers to provide information relevant to the review process and results.
• Review requests for inconsistencies or missing information and coordinate returns, clarifications, and communications with Acentra Health Administrative staff and appropriate Tennessee Medicaid departments in accordance with established processes.
• Monitor the Outstanding MNR Report throughout the day to track deliverables and prioritize workload accordingly.
• Coordinate MCC witnesses with the Office of Fair Hearings, including prehearing conferences and witness scheduling.
• Edit assigned medical necessity reviews and collaborate with Physicians to address quality issues, errors, and opportunities for improvement.
• Collaborate with Acentra Health Administrative staff and the Medical Director to identify and implement process changes that improve efficiency and quality.
• Assist the Medical Director with communications to appropriate Tennessee Medicaid staff regarding quality concerns related to the MCCs, as needed.
• Assist the Senior Clinical Review Advisor with conducting and managing medical necessity review and hearing witness training for Reviewers.
• Support quarterly quality assurance activities, as needed.
• Read, understand, and adhere to all corporate policies, including policies related to HIPAA and its Privacy and Security Rules.

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/Experience

• Active, unrestricted Registered Nurse (RN) license from the state where you reside or compact multi-state
• Bachelor's degree in a related field in accordance with state requirements
• 2+ years of recent nursing or medical records experience
• Must have a dedicated home office and reliable internet access to allow for secure viewing of protected health information

Preferred Qualifications/Experience

• Utilization Review and/or Quality Assurance experience
• Experience with Medicaid rules and regulations
• Training in continuous quality improvement approaches and methods
• Excellent verbal communication and customer service skills, with the ability to build and maintain effective relationships while remaining courteous, patient, and professional in stressful situations
• Strong written communication skills, including proficiency in grammar, punctuation, and spelling
• Flexibility and ability to collaborate effectively as a team member and support team decisions
• General computer proficiency with the ability to learn and navigate software applications including Microsoft Office suite as needed
• Strong organizational and prioritization skills, with the ability to manage multiple assignments and work independently

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.

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.

USD $91,760.00 - USD $105,000.00 /Yr.