Nurse Clinical Reviewer - RN (Remote U.S.)

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 seeks a Nurse Clinical Reviewer – RN (Remote U.S.) to join our growing team.

Job Summary:

Our Nurse Clinical Reviewer – RN will use clinical expertise to review 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.

Job Responsibilities:

• Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care.
• 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 on 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 policies, procedures, and guidelines.
• Actively cross-trains to perform duties of other contracts within the Acentra network to provide a flexible workforce to meet client/consumer needs.
• Other duties as assigned.

Requirements

Required Qualifications/Experience:

• Active unrestricted RN license in the State of North Dakota or a compact state license.
• Utilization Review (UR) and/or Prior Authorization or related experience.
• Direct experience in a clinical setting or other applicable State and/or Compact State clinical experience.
• Strong clinical assessment and critical thinking skills.
• Knowledge of InterQual OR American Society of Addiction Medicine (ASAM) guidelines.
• Ability to prioritize, assign, and follow up on work.
• Ability to problem solve.
• Ability to provide technical consultation and policy interpretation.
• Excellent customer service.
• Excellent written and verbal communication skills.
• Microsoft Office basic skills.

Preferred Qualifications/Experience:

• Knowledge of InterQual OR American Society of Addiction Medicine (ASAM) criteria.
• Knowledge of current National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Commission (URAC) standards.

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.

We do this through our people.

You will have meaningful work that genuinely improves people's lives nationwide. Our company cares about our employees, giving you the tools and encouragement you need to achieve the finest work of your career.

Thank You!

We know your time is valuable, and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may interest you. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team