Clinical Reviewer

Acentra; Arkansas; Remote; USD 39,000 - 54,000; Full time

Benefits offered by this job

Health insurance

Paid time off

Retirement plan

Job summary

Acentra Health, a national leader in health solutions, is seeking a Clinical Reviewer to apply clinical expertise to review medical records against contract criteria. This fully remote role requires Arkansas residency and focuses on prior authorization, continued stays, and quality reviews for behavioral health providers.

Collaborate with leadership to monitor provider trends, ensure medical necessity, and educate providers on reconsideration and appeal processes while upholding privacy, ethics,

Qualifications

• Active, unrestricted Arkansas licensure in Social Work or Counseling or Psychology, in good standing.
• Behavioral Health Master’s degree from an accredited program.
• Minimum 2 years in behavioral health with utilization reviews or case management.
• Ability to handle HIPAA confidential information with discretion.
• Strong interfacing skills with multiple providers across settings.
• Knowledge of medical, psychiatric, and psychological terminology and treatment planning.

Responsibilities

• Review medical records against criteria in contract requirements.
• Complete prior authorizations and retrospective reviews for behavioral health services.
• Collaborate with Clinical Director and Team Supervisor on provider trends and policy improvements.
• Determine medical necessity of services in collaboration with Medical Director.
• Serve as a resource for behavioral health providers and educate on reconsideration/appeal processes.
• Maintain client privacy, confidentiality, and compliance with regulatory standards.
• Read, understand, and adhere to corporate policies including HIPAA privacy and security rules.

Skills

HIPAA compliance

Provider engagement

Strong communication

Behavioral health knowledge

Clinical review

Education

Behavioral health master’s degree

Tools

Microsoft Office

Job description

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 Reviewer to join our growing team.

Job Summary:

• The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements.
• Completes prior authorization, continued stay, and retroactive and retrospective quality reviews for Inpatient and Outpatient Behavioral Health Providers.
• Collaborates with the Clinical Director and Team Supervisor to:
  • Monitor provider trends
  • Review government‑funded behavioral health program utilization activities
  • Recommend internal policies, procedures, and processes
• Collaborates with Team Supervisor and Medical Director to determine Medical Necessity of services.
• Serves as a resource for Behavioral Health providers.
• Assists Provider Relations Specialist with program‑specific education and training.
• Maintains client privacy, confidentiality, and safety at all times.
• Ensures adherence to ethical, legal, and accreditation/regulatory standards.

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 quality monitoring activities.
• Maintains current knowledge base related to review processes and clinical practices.
• Performs all applicable review types as workload indicates.
• Fosters positive and professional relationships with internal and external customers.
• Attends training and scheduled meetings for current/updated information.
• Cross trains to provide flexible workforce to meet client/customer needs.
• Conducts initial and concurrent prior authorization and retrospective reviews for Behavioral Health services.
• Evaluates the quality and compliance of service documentation in client records, ensuring adherence to Arkansas Medicaid regulations.
• Refers cases to the Physician Reviewer for medical necessity determinations when appropriate.
• Serves as a liaison between the organization and Behavioral Health Providers throughout the review process.
• Provides education to Behavioral Health Providers on the Reconsideration and Appeal process.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

This is a fully remote position where you must reside and work in the state of Arkansas.

There is no required Travel for this role.

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:

• Hold an active, unrestricted Arkansas licensure in Social Work OR CounselingOR Psychology issued by the Arkansas Social Work Licensing Board OR Arkansas Board of Examiners in Counseling and Marriage & Family Therapy OR Arkansas Psychology Board in good standing, in one of the following:
  • LCSW,LMSW
  • LAMFT,LMFT
  • LAC,LPC
  • LPE,LPE-I
• A Behavioral Health Master's degree from an accredited college or university in a related field.
• 2+ years of experience in a behavioral health setting, conducting utilization reviews or behavioral health case management.
• Ability to handle HIPAA confidential information with discretion.
• Skilled in interfacing with multiple providers across various settings.
• Strong knowledge of:
  • Medical, psychiatric, and psychological terminology
  • Mental health assessment tools and treatment plans
  • Delivery of behavioral health services across acute inpatient, and outpatient home and community settings
• Familiarity with government‑funded behavioral health programs, including their policies and procedures.
• Excellent interpersonal skills for building rapport with physicians, behavioral health providers, and family members.
• Highly responsible, self‑motivated, and detail‑oriented with strong listening, verbal, and written communication skills.
• Solid clinical skills for assessing services based on clinical record reviews.
• Excellent written and verbal communication skills.

Preferred Qualifications/Experience:

• Experience with Child and Adolescent Behavior.
• Experience in Utilization Review (UR) and Utilization Management (UM) within behavioral health or medical settings.
• Clinical quality review experience, including the evaluation of medical records.
• Familiarity with medical necessity review criteria specific to Arkansas Medicaid.
• In-depth knowledge of Arkansas Medicaid behavioral health policies and procedures.
• Proficient in automated review systems and Microsoft Office Suite.

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.

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.

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.

Compensation

The pay 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.