CAP Clinical POC Reviewer; Part-Time

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.

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.

Acentra Health is looking for a CAP Clinical POC Reviewer to join our growing team.

Job Summary:

• The position utilizes clinical expertise to review, evaluate, and process Home and Community-Based Services (HCBS) waiver requests, Plans of Care, reassessments, medical records, and related documentation against applicable clinical criteria, Medicaid policies, waiver requirements, contractual obligations, and program standards.

Responsibilities:

• Conducts clinical reviews of service plans/Plans of Care (POC) and other assigned review types in accordance with contract requirements, regulatory standards, and clinical guidelines.
• Ensures timely, accurate, and compliant case determinations, including the preparation of denial determinations and related correspondence when applicable.
• Meets established productivity, quality, and turnaround time expectations.
• Performs second-level reviews and supports quality monitoring activities as assigned.
• Monitors and prioritizes workload to ensure service levels and departmental objectives are met.
• Serves as a clinical resource and liaison to internal and external stakeholders, supporting issue resolution and customer service needs.
• Maintains current knowledge of review processes, clinical practices, regulatory requirements, and program updates through ongoing training and development.
• Collaborates with leadership and team members to support operational goals, process improvement initiatives, and continuity of operations.
• Provides cross-training and cross-coverage across review functions, including support for other review queues, quality activities, and staff education as needed.
• Builds and maintains positive, professional relationships with internal and external customers.
• Complies with all corporate policies, including HIPAA Privacy and Security requirements.
• 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.

Required Qualifications

• Active, unrestricted Registered Nurse license in a Compact state.
• Minimum of two years of relevant experience in clinical services, case management, utilization management, healthcare, critical thinking, legal requirements, or healthcare policies and procedures.
• Demonstrated knowledge and skills equivalent to advanced-level practice.
• Knowledge of medical records, medical terminology, and disease processes.
• Excellent written and verbal communication skills.
• Ability to work independently, prioritize tasks, and manage multiple projects simultaneously in a fast-paced environment.

Preferred Qualifications

• Master's Degree from an accredited college or university in a related field.
• Experience working in a regulated environment.
• Knowledge of and experience reviewing and participating in legal claims or polices from a clinical perspective.
• Proficiency with Microsoft Office applications and other systems required to perform assigned responsibilities.
• Ability to establish and maintain positive working relationships with internal and external stakeholders.
• Ability to communicate concerns and recommendations professionally.
• Ability to collaborate effectively in a team environment.

We are a team of experienced and…