Clinical Reviewer

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.

Job Summary and Responsibilities

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

**This is a remote position**

Job Summary:

Review medical records against criteria, contract requirements, and regulatory standards. Employ critical thinking to determine medical appropriateness while meeting production goals and QA standards. Ensure day-to-day processes align with regulatory benchmarks, ensuring precision and compliance in medical record reviews.

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 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 for 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 for current/updated information.
Cross trains and perform duties to provide flexible workforce to meet client/customer needs.
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Qualifications

Required Qualifications:

Active unrestricted LPN or RN license in the state of Indiana or a Compact clinical license per contract requirements.
5+ years of clinical experience in an acute, behavioral health, or med-surgical environment.
2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization or related experience.
2+ years of knowledge of medical necessity review experience.
2+ years of knowledge of InterQual criteria and/or Milliman Care Guidelines (MCG).
Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively.
Strong clinical assessment and critical thinking skills required.
Excellent written and verbal communication skills required.
Flexibility and strong organizational skills are needed.

Preferred Qualifications:

Knowledge of current NCQA/URAC standards is strongly preferred.
Ability to work in a team environment.
Proficient in Microsoft Office.
Efficient time management, including the ability to prioritize tasks, and meet deadlines.
Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.

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.

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."

Thank You!

We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may be of interest. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

Visit us at Acentra.com/careers/

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, gender identity, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

Pay Range

USD $22.69 - USD $39.19 /Hr.

Acentra Health

McLean (VA)

Remote

USD 100,000 - 125,000

Full time

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