Clinical Review Specialist - RN (with occasional travel to Nashville, TN)

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. 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 seeking a Clinical Review Specialist who can occasionally travel to Nashville, Tennessee, to join our growing team.

Job Summary:

The purpose of this position is to review medical records, prepare cases for physician review, and perform related activities for selected cases on a timely, accurate, and efficient basis. This selected candidate will prepare reports and other documentation for medical necessity reviews with special attention to State and managed care contractor (MCC) policies.

Job Responsibilities:

• Perform required non-physician review activities within specified timeframes and contractual guidelines.
• Communicate (verbally and/or in writing) with external customers to furnish information relevant to the review process and results.
• Contract-specific formatting of each medical necessity review, including the statement of the appealed services and citation of State Medicaid Rules. Insertion of the appropriate State Medicaid Office Reference Manual criteria and/or State.
• Medicaid Clinical Criteria are based on the appealed service(s) and specific to the enrollee’s population eligibility.
• Monitor and review requests for inconsistencies requiring a return, request clarification from the appropriate State Medicaid department, or communicate with the appropriate State Medicaid department. Returns, clarifications, and communications must follow established processes.
• Communicate with Acentra Health Administrative staff regarding returns, clarifications, and communications with Tennessee (TN) Medicaid departments via established processes.
• Monitor MRU Outstanding MNRs Report multiple times daily to be aware of the current state of deliverables and plan workload accordingly.
• Edit assigned written medical necessity reviews within the TN Medicaid contract.
• Collaborate directly with Reviewers regarding quality issues or errors in each medical necessity review.
• Formal completion of all medical necessity reviews following established processes.
• Collaborate with Acentra Health Administrative staff and the Medical Director regarding process changes to increase efficiency and quality.
• Assist the Medical Director in communications with the appropriate TN Medicaid staff regarding quality concerns related to the MCCs, as needed.
• Assist the Clinical Review Specialist II to perform and manage medical necessity review training and hearing witness training for all Reviewers.
• Support quarterly quality assurance activities as needed.
• Maintain open lines of communication with other Nurses, Reviewers, and Acentra Health.

** This is a full-time, direct hire, Exempt level position with Benefits. **

** The work hours for this role are Monday through Friday from 8:00 AM to 5:00 PM in the Central Time Zone. **

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 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 interest you. Best of luck in your search!

~ The Acentra Health Talent Acq