Utilization Clinical Reviewer - (LCSW/LMFT/LPCC/LCPC) - Remote within California

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.

Position Overview

Utilizing clinical expertise, this role involves reviewing medical records against appropriate criteria, employing critical thinking and decision-making skills to assess the medical appropriateness of psychiatric inpatient care. Maintaining production goals and QA standards, this position ensures the accuracy and consistency of the Psychiatric Inpatient Concurrent Review process with the California Mental Health Services Authority (CalMHSA). Compliance with NCQA, URAC, and other regulatory standards is a key aspect

Part-Time/Full-Time Clinical Reviewer - Remote (California License Required)

Job Responsibilities

• Review and interpret patient records against established criteria to determine medical necessity and care appropriateness, ensuring documentation supports service requirements.
• Determine approval or initiate referrals to the physician consultant, processing decisions and providing detailed denials as needed.
• Accurately and timely abstract review-related data onto appropriate review tools and submit all administrative documents to relevant parties.
• Continuously reassess review processes for improvement opportunities and facilitate changes as necessary.
• Foster positive relationships, acting as a liaison with internal/external stakeholders to facilitate the review process and maintain professionalism.
• Attend training, meetings, and maintain updated information for review purposes.
• Ensure medical record confidentiality by adhering to HIPAA policies and maintaining proper computer security measures.
• Utilize proper communication etiquette and adhere to ACENTRA HEALTH policies in verbal and written interactions.
• Additional Accountabilities This list may expand to include additional duties deemed necessary by management.

Required Qualifications and Experince

• Minimum of five (5) years of experience managing or working with Medicaid, government health plans, or hospital programs is required.
• Active California Counseling License Required (e.g., LPCC, LCPC, LCMHC, LMHC, LCSW).
• Graduation from an accredited Master's Degree Program.
• Knowledge of the Parity in Mental Health and Substance Use Disorder Services Final Rule (Parity Rule; Title 42 of the CFR, part 438.910).
• Familiarity with psychiatric disorders and standards of practice related to determining Level of Care and mental health assessments.
• Knowledge and understanding of public sector services and supports.
• Proficiency in Microsoft Excel, Word, PowerPoint, Teams, and Outlook.
• Ability to diagnose clinically while accounting for psychological and behavioral issues.
• Proficient with computer equipment and web-based software for conducting work.
• Strong communication skills for interacting with healthcare professionals, patients, and families.
• Detail-oriented with effective prioritization and task execution abilities.
• Proficiency in psychological, emotional, behavioral, and physical function assessment and analysis.
• Understanding of Medicaid programs with experience navigating similar complex projects.
• Ability to develop level-of-care recommendations based on clinical evaluations.

· 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.

EOE AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin