Clinical Reviewer - RN - (Remote)

Clinical Reviewer (Remote)

• Are you an experienced Clinical Reviewer looking for a new challenge?
• Do you value care management and quality improvement?
• Are you motivated, energetic, and excited to become part of the Acentra Health team?

If so, you might be our next new team member!

Note: This position is a part-time, PRN position. Work can be performed from home.

Who we need:

The Clinical Reviewer utilizes 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 NCQA, URAC and other regulatory standards.

Why us?

Acentra Health is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting.

People Focused. Mission Driven.

Shape the future of healthcare with us. We are mission driven to improve lives through healthcare quality and clinical expertise.

We do this through our people.

At Acentra Health, you can do meaningful work that makes a real difference for the lives of individuals across the country. We are an organization that cares deeply about our employees and we provide the training and support to do the best work of your career.

Benefits are a key component of your rewards package at Acentra Health. These benefits are designed to provide you and your family additional protection, security, and support for both your career and your life away from work. They are comprehensive and fit a variety of needs and situations. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more.

What you’ll do:

• Reviews and interprets patient records to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
• Communicate with clients and experts regarding the independent review process and submission of documentation/reports via the client portal or expert portal.
• Coordinate the recruitment of reviewers from the Independent Review Panel according to the Reviewer Recruitment and Selection policy. Discuss the specialty background of reviewers to be assigned to case-specific panels for case reviews with the Director of Operations, Manager Clinical Review and/or the Medical Director if applicable.
• Ensure that a conflict of interest does not exist for the reviewer(s) on a case-by-case basis.
• Evaluate patient medical records for sufficient documentation and request additional medical records from the client via telephone and written communication. Ensure records are sent to the reviewer in an organized manner.
• Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.
• Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
• Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
• 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.

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

What you’ll need:

Qualifications

• Active Registered Nurse (RN) license required.
• Bachelor’s degree or advanced certifications preferred.

Knowledge, Skills, Abilities

• Knowledge of current NCQA/URAC standards strongly preferred
• Knowledge of the organization of medical records, medical terminology, and disease process required.
• Strong clinical assessment and critical thinking skills required.
• Excellent verbal and written communication skills required.
• Ability to work in a tea