Clinical Reviewer - Rn (Remote U.s.)

Following a 2022 merger of CNSI and Kepro, Acentra Health combines clinical services, technology solutions, and data analytics to accelerate better health outcomes. This is a great time to join our team of passionate individuals working together to pursue the most effective solutions to today’s complex healthcare challenges. Our culture is fueled by passion and driven by purpose.

Clinical Reviewer

• Are you an experienced Clinical Reviewer looking for a new challenge?
• Are you looking to join a team that ensures a collaborative and inviting culture where everyone can thrive?

If so, you might be our next new team member!

Who we need:

The Nurse Clinical Reviewer 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.

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.

Singularly Focused. Mission Driven.

Accelerating Better Outcomes is our Mantra! We are mission-driven to innovate health solutions that deliver maximum value and impact.

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 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.

What you’ll do:

• Review and interpret patient records and compare against criteria to determine medical necessity and appropriateness of care; determine 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 in 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.
• Performs ongoing reassessment of the review process to offer opportunities for improvement and/or change.
• Foster positive and professional relationships and act as a 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.
• Maintains medical records confidentiality at all times 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 KEPRO policies, procedures, and guidelines
• Actively cross-trains to perform duties of other contracts within the KEPRO network to provide a flexible workforce to meet client/consumer needs.

What you’ll need:

Required Qualifications / Experience

• Active unrestricted compact RN license OR RN license specifically for the state of TN.
• 1+ years Utilization Review (UR) AND/OR Prior Authorization OR related experience.
• 3+ years of direct experience in a clinical setting OR other applicable State and/or Compact State clinical experience or license.
• 2+ years of clinical experience in an acute or med-surgical environment.
• Strong clinical assessment and critical thinking skills.

Required Knowledge, Skills, Abilities

• 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.
• Proficiency in Microsoft Office and Internet/web navigation

Preferred Knowledge, Skills, Abilities

• Knowledge of InterQual criteria.
• Knowledge of current NCQA/URAC standards.

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

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.