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

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.

At Acentra Health, we embrace emerging technologies, including artificial intelligence and advanced analytics that can be utilized to improve processes, enhance decision-making, and drive better health outcomes. We value professionals who are curious about new technologies and motivated to use innovative tools to increase efficiency, quality, and impact in their roles.

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.

** This position is Monday - Friday 8:00am - 5:00pm MST **

Responsibilities:

• Review and interpret patient records to assess medical necessity and appropriateness of care; verify that documentation supports the need for services.
• Approve services or refer cases to a physician consultant; process consultant decisions and ensure denial correspondence includes clear, detailed reasoning.
• Accurately and promptly abstract review-related data using appropriate tools and methods; submit all administrative and review documentation in a timely manner.
• Support discharge planning to promote understanding of physician orders and reduce risk of readmission.
• Continuously evaluate the review process to identify opportunities for improvement and implement changes as needed.
• Build and maintain positive, professional relationships with internal and external stakeholders; serve as a liaison to ensure effective collaboration and team alignment.
• Safeguard medical record confidentiality through proper password use, secure file maintenance, and strict adherence to HIPAA policies.
• Demonstrate professional communication skills, including proper telephone etiquette and compliance with organizational policies and guidelines.
• Crosstrain on other contracts within the Acentra Health network to provide workforce flexibility and meet client needs.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

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

Required Qualifications

• Active, unrestricted license as a Registered Nurse (RN) in any state and/or a Compact State clinical license, as required by contract.
• Graduation with a Diploma in Nursing or from an accredited nursing program (Associate, Bachelor or higher-level Degree).
• 2+ years of clinical experience in an acute OR med-surgical environment.

Preferred Qualifications

• 1+ years of experience in Utilization Management (UM), Utilization Review (UR) and/or Prior Authorization.
• 1+ years of experience applying clinical criteria in utilization review processes (e.g., InterQual and/or MCG).
• 1+ years of experience with medical record organization, medical terminology, and disease process.
• Behavioral Health Nursing experience.
• Familiarity with current National Committee for Quality Assurance (NCQA) standards.
• Familiarity with Utilization Review Accreditation Commission (URAC) standards.
• Proficiency in Medical Record Abstraction.
• Strong clinical assessment and critical thinking abilities.
• Exceptional verbal and written communication skills.
• Ability to collaborate effectively in a team environment.
• Demonstrated flexibility and strong organizational skills.
• Proficiency in Microsoft Office Suite and web navigation.

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!

We are committed to providing a secure and positive hiring experience. Depending on the role, interviews may be conducted virtually, in person, or through a combination of both. As part of our recruitment process, candidates may be asked to participate in identity verification measures to help ensure the integrity of the hiring process.

~ The Acentra Health Talent Acquisition Team

Visit us at https://careers.acentra.com/us/jobs

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.

Experience in Lieu of Degree

For non-clinical roles, or when not required by the contract specifically, the Company acknowledges that practical, hands-on experience can provide skills and competencies equivalent to formal education. As such, in cases where a Bachelor's degree may be required, the Company will accept a minimum of six (6) years of directly relevant professional experience in lieu of a degree. In instances where the candidate has an Associate's degree, the Company will accept a minimum of three (3) years of directly relevant professional experience in lieu of the Bachelor's degree.

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."