Clinical Review RN — Utilization Management & InterQual

Acentra; Florida; On-site; USD 39,000 - 54,000; Full time

Job summary

Acentra Health is seeking a Clinical Reviewer-RN to review medical records against criteria and contract requirements to determine medical appropriateness. You will ensure accuracy, manage daily workload, and support quality monitoring initiatives in a fast-paced environment.

The role requires an active RN license, a Bachelor’s degree, and strong clinical assessment with excellent communication skills. Experience with InterQual criteria or utilization management is a plus.

Qualifications

• Bachelor’s Degree and a minimum of 2 years of clinical experience.
• Active unrestricted RN in the applicable State and/or Compact State clinical license per contract requirements.
• Knowledge of the organization of medical records, medical terminology, and disease process.
• Strong clinical assessment and critical thinking skills.
• Excellent written and verbal communication skills.

Responsibilities

• Assures accuracy and timeliness of all applicable review type cases within contract requirements.
• Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
• In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas.
• Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns.
• Functions as providers’ liaison and contact/resource person for provider customer service issues and problem resolution.
• Performs all applicable review types as workload indicates.
• Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
• Attends training and scheduled meetings and for maintenance and use of current/updated information for review.
• Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs.

Skills

RN license

Clinical experience

Medical terminology

Critical thinking

Written communication

Verbal communication

Education

Bachelor's degree

Job description

Acentra Health is seeking a Clinical Reviewer-RN to review medical records against criteria and contract requirements to determine medical appropriateness. You will ensure accuracy, manage daily workload, and support quality monitoring initiatives in a fast-paced environment.

The role requires an active RN license, a Bachelor’s degree, and strong clinical assessment with excellent communication skills. Experience with InterQual criteria or utilization management is a plus.