Clinical Reviewer

About the job

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 - LPN/LVN or RN (remote U.S.) 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.

• This position is remote within the United States, but applicants must be clinically licensed for the State of Indiana or have a compact license.***
• Work Schedule: Five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays***

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.
• Functions as providers' liaison for customer service issues and problem resolution.
• 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.
• 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:

• Active, unrestricted LPN/LVN or RN license in the state of Indiana or a Compact state clinical license.
• Associate's degree (bachelor's preferred) or Practical/Professional nursing diploma from an accredited nursing school, college, or university.
• 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience.
• 2+ years of medical necessity review experience.
• 1+ years of InterQual criteria and/or Milliman Care Guidelines (MCG) experience.
• Knowledge of medical records, medical terminology, and disease processes.
• Strong clinical assessment and critical thinking skills.
• Excellent written and verbal communication skills.
• Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively.
• Flexibility and strong organizational skills.
• Ability to work five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays.

Preferred Qualifications

• 3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment.
• Knowledge of current National Committee for Quality Assurance (NCQA) standards.
• Knowledge of Utilization Review Accreditation Commission (URAC) standards.
• 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.