United States onlyCNSI and Kepro are now Acentra Health! 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 company’s mission, actively engage in problem-solving, and take ownership of your work daily. 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.
Acentra is looking for a Clinical Reviewer to join our growing team.
Job Summary:
As a Registered Nurse Clinical Reviewer within our team, you will harness your extensive clinical knowledge to conduct thorough reviews and evaluations of medical records based on established criteria and in compliance with our contractual commitments. This crucial role demands acute critical thinking and decisiveness to assess the medical suitability of cases, all while achieving production targets and maintaining the highest levels of quality assurance.
As a RN Clinical Reviewer, you will play a pivotal role in managing daily operations, ensuring adherence to regulatory standards such as NCQA, URAC, and other relevant industry benchmarks. This position offers the unique opportunity to take the reins of your career, contributing to enhanced outcomes and joining a team of dedicated professionals committed to delivering outstanding health solutions in the public sector. This remote position does not require any interaction or communication with patients and is non-patient-facing.
** This position requires the selected candidate to work Monday - Friday from 9:00 AM - 5:30 PM Eastern Standard Time. Some on call time may be required in the evenings and on weekends.
Job Responsibilities:
- Conduct thorough reviews of patient records, comparing them against established criteria to determine the medical necessity and appropriateness of care.
- Make well-informed decisions regarding the need for services, drawing on the comprehensive analysis of medical documentation.
- Assess cases and either approve them directly or refer them to physician consultants for further evaluation, ensuring that decisions, particularly denials, are thoroughly documented with clear rationales.
- Develop and sustain positive, professional relationships, serving as an effective liaison between internal teams and external partners.
- Promote teamwork and seamless collaboration to enhance the efficiency of the review process.
- Participate in scheduled training sessions and meetings to stay abreast of the latest developments relevant to your role and responsibilities.
- Maintain the highest standards of confidentiality in handling medical records, strictly adhering to HIPAA regulations and employing secure practices for file management and computer usage.
- Exhibit good customer and patient service, utilize both verbal and written communication effectively, in line with Acentra Health's standards and guidelines.
- Actively participate in cross-training opportunities to gain proficiency in managing duties across various contracts within the Acentra Health network, thereby supporting a versatile and adaptive workforce
Required Qualifications/Experience:
- Must possess an active, unrestricted RN license within your state of practice.
- Licensed Registered Nurse with minimum 3 years of experience in direct patient care within a clinical setting or comparable experience in applicable State and/or Compact State, ensuring compliance with contract requirements.
- Minimum of 1 year of experience in Utilization Review (UR), Prior Authorization, or a related field is required
- Experience with InterQual or ASAM guidelines is necessary, with a strong preference for candidates well-versed in InterQual or ASAM criteria.
- Preferred knowledge of the latest NCQA/URAC standards is highly desirable.
- Demonstrated excellence in clinical assessment and critical thinking abilities.
- Proven capability to prioritize effectively, delegate responsibilities, and ensure timely follow-up on tasks.
- Demonstrated ability to offer technical consultation and accurately interpret policies.
- Advanced problem-solving skills, with a keen aptitude for identifying and addressing challenges.
- Strong written and verbal communication skills, with the ability to convey complex information clearly and persuasively.
- Have a patient first approach with a focus on providing a superior patient and provider experience.
- Proficiency in Microsoft Office applications, including Word, Excel, and PowerPoint.
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 nationwide. Our company cares about our employees, giving you the tools and encouragement, you need to achieve the finest work of your career.
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
EOE 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.
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 compensation for this role is $33.00 to $35.00 per hour
Based on our compensation program, an applicant’s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.
