Clinical Reviewer-SCA

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.

Acentra Health is looking for a Clinical Reviewer (SCA) to join our growing team.

Job Summary:

The Clinical Reviewer supports Medicare beneficiaries by addressing healthcare concerns, communicating directly with beneficiaries and providers to resolve them quickly and professionally in alignment with CMS guidelines. This role applies clinical knowledge, critical thinking, and contract requirements to assess and explain medical appropriateness while also meeting productivity and quality standards as ensuring all daily processes comply with other regulatory requirements.

Shift Information: This position requires availability to work between 8:00 a.m. and 8:00 p.m. ET, Monday through Friday, and 10:00 a.m. to 7:00 p.m. ET on weekends and holidays.

Responsibilities:

• Call-based environment responding to beneficiary calls and voicemails within required timeframes.
• Assess concerns to determine eligibility for Immediate Advocacy facilitating frequent communication between beneficiaries and healthcare providers to resolve quality of care concerns.
• Demonstrate strong documentation skills and attention to detail in entering all interactions and case information accurately in the CMS system.
• Evaluate, and focus on daily workload and call queues; adjust work schedules daily to meet the demands of the department.
• Provide education on alternative options such as Medical Record Reviews or referrals when needed.
• Ability to multitask while engaging with callers demonstrating empathy and strong problem‑solving skills in every interaction.
• In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas
• 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
• Attend 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

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.

Required Qualifications

• Active, unrestricted Social Worker, LPN, or RN license in the applicable state and/or a Compact State license.
• 3+ years of clinical experience in a hospital or post-acute environment required.
• Knowledge of the provider types, healthcare workflows, medical terminology, and disease process required
• Strong clinical assessment and critical thinking skills required

Preferred Qualifications

• Bachelor’s Degree from an accredited college or university in a related field
• Proficiency with computer systems or similar case management software preferred.
• Some knowledge of Case Management, UR and/or Prior Authorization or related experience is preferred
• Prior experience in Medicare, QIO, care coordination, health plan operations, or regulatory healthcare environments.
• Experience in 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

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

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, 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.  

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 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.”