RN Clinical Reviewer - (Remote/Must reside in the Central or Eastern region)

CNSI 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 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.

Clinical Reviewer (RN or LPN) Remote

• Are you an experienced Nurse Clinical Reviewer looking for a new challenge?
• Are you looking to join a team that ensures a collaborative and inviting culture where everyone can thrive?

If so, you might be our next new team member! 

Position Overview'

As a Nurse Clinical Reviewer, you'll leverage your clinical expertise to meticulously review and assess medical records against specified criteria, aligning with contractual obligations. Your role will require sharp critical thinking and decisive skills to gauge medical appropriateness while meeting production goals and upholding QA standards. Your responsibilities encompass overseeing daily operations to ensure compliance with regulatory benchmarks such as NCQA, URAC, and other industry standards.

** 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

• Review and meticulously interpret patient records, aligning them with established criteria to ascertain the medical necessity and appropriateness of care. Make informed determinations regarding service needs based on the documentation within the medical records.
• Assess and decide on approvals or initiate referrals to physician consultants. Ensure that the processing of physician consultant decisions includes detailed descriptions for any denial in corresponding documentation.
• Cultivate and maintain positive, professional relationships as a liaison between internal and external stakeholders. Foster effective teamwork and collaboration to streamline the review process.
• Attend scheduled training sessions and meetings, staying updated with current information pertinent to the review process.
• Uphold confidentiality standards for medical records through secure file maintenance, adherence to HIPAA policies, and proper use of computer passwords.
• Demonstrate proper telephone etiquette and exercise judicious use of verbal and written communication methods, adhering to Acentra Health's policies, procedures, and guidelines.
• Actively engage in cross-training to proficiently execute duties across various contracts within the Acentra Health network.
• Contribute to a flexible workforce, ensuring readiness to meet the diverse needs of clients and paitients.
• Perform any other duties as assigned, contributing to the efficiency and effectiveness of the team's operations.

Required Qualifications; Knowledge, Skills and Experience

• Active, unrestricted LPN or RN State license.
• Licensed Registered Nurse with 2 + years of experience in direct patient care within a clinical setting.
• Minimum of 1+ years of experience in UR and/or Prior Authorization, or related field.
• Minimum of 3 years of direct clinical experience in a healthcare setting or relevant experience in applicable State and/or Compact State with adherence to contract requirements.
• Familiarity with InterQual or ASAM guidelines.
• Strong preference for familiarity with InterQual or ASAM criteria.
• Preferred knowledge of current NCQA/URAC standards.
• Demonstrated strong clinical assessment and critical thinking skills.
• Ability to effectively prioritize, delegate, and follow up on tasks.
• Aptitude for providing technical consultation and interpreting policies.
• Proficient problem-solving capabilities.
• Exceptional written and verbal communication skills.
• Strong proficiency in Microsoft Office applications.
• Excellent customer service.

 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. St