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

Job Summary Acentra Health is looking for a Clinical Reviewer - RN - PRN (Remote U.S.) to join our growing team. Responsibilities Review medical records against criteria, contract requirements, and regulatory standards. Employ critical thinking to determine medical appropriateness while meeting production goals and QA standards. Ensure day‑to‑day processes align with NCQA, URAC, CMS, and other regulatory benchmarks, ensuring precision and compliance in medical record reviews. Review and interpret patient records, comparing them against criteria to determine medical necessity and appropriateness of care; assess if the medical record documentation supports the need for services. Initiate a referral to the physician consultant and process physician consultant decisions, ensuring the reason for denial is described in sufficient detail in correspondence. Abstract review‑related data/information accurately and promptly using the appropriate means on an appropriate review tool. Ensure accurate and timely submission of all administrative and review‑related documents to the company. Perform ongoing reassessment of the review process to identify improvement and/or change opportunities. Foster positive and professional relationships and liaise with internal and external customers to ensure effective working relationships and team building, facilitating the review process. Be responsible for attending training and scheduled meetings and maintaining and using current/updated information for review. Maintain medical records confidentiality by properly using computer passwords, maintaining secured files, and adhering to HIPAA policies. Utilize proper telephone etiquette and judicious use of other verbal and written communications, following company policies, procedures, and guidelines. Actively cross‑train to perform duties of other contracts within the company network to provide a flexible workforce to meet client/consumer needs. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules. Preferred Availability Preferred availability is during business hours (8:00 AM‑5:00 PM, Monday‑Friday). Scheduling may be flexible based on individual availability and occasional weekend coverage may be requested as needed. Required Qualifications / Experience Active, unrestricted Registered Nurse (RN) License in South Carolina, or an RN compact state license. Associate’s, Bachelor’s degree (or Diploma) in Nursing. 2+ years of clinical experience in an acute OR med‑surgical environment. 1+ years of work experience in Utilization Review (UR), Utilization Management (UM), OR Prior Authorization. 1+ years of knowledge of InterQual criteria. Remote work experience. Preferred Qualifications / Experience Knowledge of Utilization Review Accreditation Commission (URAC) standards. Knowledge of Medicare (CMS) guidelines. Medical Record Abstracting skills. Clinical assessment and critical thinking skills. Excellent verbal and written communication skills. Ability to work in a team environment. Flexibility and strong organizational skills. Proficient in Microsoft Office and Internet/Web Navigation. Benefits This position includes access to select Acentra Health benefits and programs, such as participation in the Acentra Health 401(k) Plan with company match, access to wellness and employee discount programs, and Employee Assistance Program (EAP) resources. Compensation The pay range for this position is USD $28.37 - USD $36.00 /Hr. EEO Statement 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. #J-18808-Ljbffr