Clinical Reviewer QOC

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 Clinical Reviewer to join our growing team.

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, CMS, and other regulatory standards. Position is required to be available to work any hours under the contract's Scope of Work, including rotating weekends and holidays. Candidate may be required to work additional hours as required by contract, work volume, and as directed by Kepro leadership.

*Position is remote*

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
• Initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for outcome is described in sufficient detail on correspondence at a level the beneficiary can understand
• Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties
• Performs ongoing reassessment of review process to offer opportunities for improvement and/or change
• Fosters positive and professional relationships and act 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, adherence to HIPAA polices
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following KEPRO 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

• Active unrestricted LPN or RN State and/or Compact State license
• Graduation from an accredited Technical, Diploma, Associate or Bachelor Degree Nursing Program
• Minimum two years of clinical experience in an acute , med-surgical, post-acute or rehabilitation environment required
• Minimum of one year UR and/or Prior Authorization or related experience
• Must be proficient in computer skills including Microsoft Office and internet/web navigation
• Knowledge of current NCQA/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

Visit us at Acentra.com/careers/

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, disability, status as a protected veteran, or any other status protected by applicable Federal, State, or Local law.

Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide additional protection, security, and support for your career and life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

Compensation

The pay range for this position is $22.56 - $33.00

"Based on our compensation philosophy, an applicant's placement in the pay range will depend on various considerations, such as years of applicable experience and skill level."