Regional Mentor QA Reviewer (Hybrid)

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 Health seeks a Regional Mentor QA Reviewer (RN - Hybrid) to join our growing team.

Job Summary:

The Regional Mentor travels to perform education and initial/re-evaluation assessments of Aged and Disabled Waiver members for the purposes of determining program medical eligibility. Provides education to applicants/members and conducts the Pre-Admission Screening assessment. Manages a caseload of assigned members to ensure that assessments are scheduled, appropriate persons are in attendance, assessments are performed and data is entered into the APS CareConnection© within prescribed timelines.

• Travel to homes and facilities within the catchment area
• Must be able to accurately assess medical conditions and symptoms and functional abilities

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.

Job Responsibilities:

 Conducts mediations at the request of beneficiaries who have had an adverse decision for all programs.

Works to negotiate settlements during mediations

Is knowledgeable of NC Medicaid Recipient Due Process Rights and Prior Approval Policies and Procedures in order maintain appropriate systems for implementation

and compliance .

• Researches cases in appeal to prepare for mediation to include PCG records as well as independent assessment(s), supporting docs and comm log notes within QiReport
• Communicates with Mediations Centers to schedule mediations within timelines.
• Enters appeal results into QiReport as applicable
• Enters Results of Mediation assessment requests into QiReport as applicable

• Proactively anticipates and works to mitigate problems that could result in customer dissatisfaction or failure to deliver contracted services

• Performs other duties as assigned by management

• Performs other duties as assigned by management

Duties related to maintenance of internal databases (Atrezzo)

Supports analysis of the Mediation and Appeals process for quality improvement by maintaining information in database for tracking/trending all decisions, dates, issues and outcomes

• Maintains mediation records and reports using a database that tracks all mediation/appeal requests, dates of the requests, number of requests completed and not completed, and outcomes
• Identifies and documents specific quality indicators for monitoring and tracking the reasons for adverse appeal decisions.

Required Qualifications/Experience:

• Active and current driver’s license required; BSN preferred
• Active unrestricted RN, Social Worker, Counselors or other applicable State and/or Compact State clinical license and/or certifications.
• Associate’s Degree or Bachelor’s Degree Program
• CCM preferred and/or required per contract requirements

Preferred Qualifications/Experience:

• 2+ years’ experience with aging population or with persons with disabilities

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

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 federa