Clinical Reviewer - RN (Remote within Alabama)

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.

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.

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 reason for the denial is described in sufficient detail on correspondence.
• 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 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 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 communications, following Acentra Health policies, procedures, guidelines.
• Actively cross-trains to perform duties of other contracts within the Acentra Health network to provide a flexible workforce and meet client/consumer needs.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

The above 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.

Work Hours: Monday through Friday from 8:00 AM until 5:00 PM Central.

Required Qualifications/Experience:

• Active, unrestricted RN license in the state of Alabama.
• Must reside and work in the state of Alabama and be in good standing with the Alabama Board of Nursing.
• 2+ years of clinical experience in an acute or med-surgical environment.
• The selected candidate may not hold a concurrent working relationship with a Medicaid-enrolled provider while working on this contract.

Preferred Qualifications/Experience:

• Prior authorization review experience.
• Knowledge of InterQual criteria.
• Knowledge of current National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Commission (URAC) standards.
• Medical record abstracting skills.
• Knowledge of the organization of medical records, medical terminology, and disease processes.
• 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.

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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 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

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.

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 be of interest. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

Visit us at Acentra Health

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

Compensation

The pay for this position is listed below.

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