Nurse Clinical Reviewer - RN - PRN (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 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 currently looking for a Nurse Clinical Reviewer – RN – PRN (Remote U.S.)

Job Summary

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.

** Preferred Work Schedule - Weekends and Holidays with some Weekday opportunities. **

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.
• Abstracts review related data/information accurately and timely on appropriate review tools by the appropriate means. Accurate and timely submission of all administrative and review-related documents to appropriate parties.
• Discharge planning to support understanding of physician orders and prevent readmission.
• Performs ongoing reassessment of the review process to offer opportunities for improvement and/or change.
• 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.
• 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 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.

Required Qualifications / Experience:

• Active unrestricted RN applicable State and/or Compact State clinical license per contract requirements.
• Graduation from an accredited Diploma, Associate Degree, or Bachelor’s Degree Nursing Program.

Knowledge, Skills, Abilities

• 2+ years of clinical experience in an acute or med-surgical environment.
• 1+ years Utilization Review (UR) and/or Prior Authorization or related experience.
• Knowledge of InterQual criteria.
• Medical record abstracting skills.
• Knowledge of the organization of medical records, medical terminology, and disease process.
• Strong clinical assessment and critical thinking skills.
• Excellent verbal and written communication skills.
• Ability to work in a team environment.
• Flexibility and strong organizational skills.
• Must be proficient in Microsoft Office and Internet/web navigation.

Preferred Qualifications / Experience:

• Knowledge of current National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Commission (URAC) standards.

Compensation:

The pay range for this position is $38.00-41.00 / hour.

“Based on our compensation program, an applicant’s position in the salary range will depend on various considerations, such as years of applicable experience and skill level.”

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 fed