Clinical Reviewer-PRN; RN); 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.

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

Job Summary:

• The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements.

  Position is remote

  Required
  
  Work Hours:
  
  On-call weekends, holidays and evenings

Responsibilities:

• Assures accuracy and timeliness of all applicable review type cases within contract requirements.
• Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
• In collaboration with Supervisor, responsible for quality monitoring activities.
• Maintains current knowledge base related to review processes and clinical practices.
• Functions as providers' liaison for customer service issues and problem resolution.
• Performs all applicable review types as workload indicates.
• Fosters positive and professional relationships with internal and external customers.
• Attends training and scheduled meetings for current/updated information.
• Cross trains to provide 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.

Required Qualifications

• Active, unrestricted Registered Nurse (RN) License in any state, or an RN compact state License.
• A minimum of 2+ years of experience with federal CMS case processing.
• Knowledge of medical records and medical terminology.
• Skilled in reviewing, interpreting, and abstracting data from medical records.
• Strong clinical assessment and critical thinking skills.
• Excellent verbal and written communication skills.
• Must be proficient in Microsoft Office and internet/web navigation.

Preferred Qualifications

• Knowledge of IRO Accreditation (URAC) standards.
• Knowledge of Independent Review Organization (IRO).
• Knowledge of Medicare (CMS) guidelines.
• Experience with Medical Appeals.
• Ability to work in a team environment.
• Flexibility and strong organizational skills.

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…