Clinical Reviewer (SCA-Remote)

Company Overview

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 and Responsibilities

Acentra seeks a Clinical Reviewer to join our growing team.

Job Summary:

The Clinical Reviewer utilizes clinical expertise during beneficiary interaction in conjunction with contract requirements, critical thinking and utilize decision-making skills to assist with communicating medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards.

*Shift Information: This position requires availability to work between 8:00 a.m. and 8:00 p.m. ET, Monday through Friday, and 11:00 a.m. to 6:00 p.m. ET on weekends and holidays.*

Job Responsibilities:

• Assures accuracy and timeliness of all applicable review type cases within contract requirements
• Assesses, evaluates, and addresses daily workload and call queues; adjusts work schedules daily to meet the workload demands of the department
• In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas
• Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns
• Functions as providers' liaison and contact/resource person for provider customer service issues and problem resolution
• Performs all applicable review types as workload indicates
• 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
• Attends training and scheduled meetings and for maintenance and use of current/updated information for review
• Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.

Qualifications

Required Qualifications

• Active, unrestricted LPN or RN license in the applicable state and/or a Compact State license.
• Knowledge of the organization of medical records, medical terminology, and disease process required
• Strong clinical assessment and critical thinking skills required
• Medical record abstracting skills required
• 2+ years of clinical experience in a hospital or post-acute environment required.

Preferred Qualifications

• Minimum of one year UR and/or Prior Authorization or related experience.
• Requires excellent written and verbal communication skills
• Must be proficient in Microsoft Office and internet/web navigation
• Bachelor's Degree from an accredited college or university in a related field
• Some knowledge of Case Management, UR and/or Prior Authorization or related experience is preferred
• Experience in call center environment a plus
• Experience in a behavioral health setting a plus
• Bilingual (English/Spanish) a plus

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

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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 below:

"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."

Pay Range

USD $28.37 - USD $35.00 /Hr.