Clinical Reviewer (Lpn/Rn - Remote)

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 (RN or LPN) Remote

• Are you an experienced Nurse 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!
** This position requires the selected candidate to work Monday-Friday 8:00 AM - 5:00 PM Eastern (excluding Company Holidays). **

• This position may require occasional travel to Indianapolis for potential in-person quarterly team meetings and Client meetings at company expense. **

Who We Need
Our Nurse Clinical Reviewer will use 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

• Other duties as assigned
• Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
• Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Acentra Health policies, procedures, and guidelines.
• Actively cross-trains to perform duties of other contracts within the Acentra Health network to provide a flexible workforce to meet client/consumer needs.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
• Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
• Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.

What You’ll Need
Required Qualifications

• Active unrestricted LPN or RN license in the State of Indiana or a compact state license
• Strong clinical assessment and critical thinking skills required

Knowledge, Skills, Abilities

• Microsoft Office basic skills
• Knowledge of InterQual or ASAM guidelines
• Knowledge of InterQual or ASAM criteria strongly preferred
• Knowledge of current NCQA/URAC standards strongly preferred
• Ability to problem solve
• Ability to provide technical consultation and policy interpretation
• Ability to prioritize, assign, and follow up on work
• Excellent written and verbal communication skills
• Excellent customer service

Experience

• 3+ years direct experience in a clinical setting or other applicable State and/or Compact State clinical experience or license per contract requirements.
• 1+ years UR and/or Prior Authorization or related experience.

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 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
Mental And Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.
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.