Clinical Reviewer - RN - PRN (Remote within Illinois)

Company Description

Following a 2022 merger of CNSI and Kepro, Acentra Health combines clinical services, technology solutions, and data analytics to accelerate better health outcomes. This is a great time to join our team of passionate individuals working together to pursue the most effective solutions to today’s complex healthcare challenges. Our culture is fueled by passion and driven by purpose.

Job Description

Clinical Reviewer – RN - PRN (Remote within Illinois)

• Are you an experienced Utilization Management Review Nurse 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!

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.

Singularly Focused. Mission Driven. 

Accelerating Better Outcomes is our Mantra! We are mission-driven to innovate health solutions that deliver maximum value and impact. 

We do this through our people.

You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.

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. 

What you will do:

• Our Nurse Clinical Reviewer will use clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking, and decision-making skills to determine medical appropriateness while maintaining production goals and QA standards.
• Ensures day-to-day processes are conducted in accordance with contractual and regulatory standards.
• While this position offers remote work flexibility, the selected individual must maintain their residence within the State of Illinois.
• This is a PRN position ONLY.  Contingent upon the business need, you will work 2-3 days per week. 

Job Responsibilities

• Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care and determines if the medical record documentation supports the need for services. 
• Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring the reason for the denial is described in sufficient detail in correspondence. 
• Fosters positive and professional relationships and acts as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process. 
• Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review. 
• Always maintains medical records confidentiality through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies. 
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Acentra Health policies, procedures, and guidelines. 
• Actively cross-trains to perform duties of other contracts within the Acentra Health network to provide a flexible workforce to meet client/consumer needs. 

Qualifications

What you will need:

Required Qualifications / Experience

• Active unrestricted Registered Nurse license in the State of Illinois. 
• Strong clinical assessment and critical thinking skills. 
• 2+ years of Utilization Review/Management experience. 
• 5+ years of direct inpatient experience in a medical and psychiatric clinical setting.
• 1+ years of experience and knowledge of InterQual criteria. 
• Knowledge of current NCQA/URAC standards
• Experience completing retrospective reviews and long-term acute care hospital reviews. 
• Ability to prioritize, assign, and follow-up on work independently. 
• Ability to problem solve. 
• Ability to provide technical consultation and policy interpret