RN Clinical Reviewer - Remote Position (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 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.
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