RN Clinical Reviewer-URAC

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 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. 

Acentra is looking for a Clinical Reviewer to join our growing team.

Job Summary:

Review medical records against criteria, contract requirements, and regulatory standards. Employ critical thinking to determine medical appropriateness while meeting production goals and QA standards. Ensure day-to-day processes align with NCQA, URAC, and other regulatory benchmarks, ensuring precision and compliance in medical record reviews.

Job Responsibilities:

• Review and interpret patient records, comparing them against criteria to determine medical necessity and appropriateness of care; assess if the medical record documentation supports the need for services.
• Initiate a referral to the physician consultant and process physician consultant decisions, ensuring the reason for denial is described in sufficient detail on correspondence.
• Abstract review-related data/information accurately and prompt on an appropriate review tool using the appropriate means. Ensure accurate and timely submission of all administrative and review-related documents to the company.
• Perform ongoing reassessment of the review process to identify opportunities for improvement and/or change.
• Foster positive and professional relationships and act as a liaison with internal and external customers to ensure effective working relationships and team building, facilitating the review process.
• Be responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
• Maintain medical records confidentiality through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
• Utilize proper telephone etiquette and judicious use of other verbal and written communications, following company policies, procedures, and guidelines.
• Actively cross-train to perform duties of other contracts within the company network to provide a flexible workforce to meet client/consumer needs.
• Perform other duties as assigned.

Requirements

Required Qualifications/Experience

• Associate degree or bachelor’s certificate.
• Active unrestricted RN license or other applicable State and/or Compact State clinical license per contract requirements.
• Medical record abstracting skills.
• Knowledge of the organization of medical records, medical terminology, and disease process.
• Minimum two years of clinical experience in an acute or med-surgical environment.

• Strong clinical assessment and critical thinking skills.
• Excellent verbal and written communication skills.
• Must be proficient in Microsoft Office and internet/web navigation. .

Preferred Qualifications/Experience:

• Knowledge of InterQual criteria strongly preferred.
• Minimum of one year UR and/or Prior Authorization or related experience.
• Knowledge of current NCQA/URAC standards strongly preferred.
• Ability to work in a team environment.
• Flexibility and strong organizational skills needed.

Benefits

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 outco