Clinical Assessor (RN - Mediation and Appeals - Remote in NC)

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.

The Clinical Assessor (Mediations and Appeals) ensures that mediations are scheduled, mediations are performed within timelines and data is entered into QiRePort and the Mediation Tracker within prescribed timelines. The Clinical Assessor (Mediations and Appeals) coordinates with the M&A Manager on decisions and issues, and communicates with the Acentra team as appropriate regarding determinations and other clinical matters.

Conduct mediations at the request of beneficiaries who have an adverse decision for the CAP programs. Must be able to accurately assess medical conditions and symptoms and functional abilities. Identify and document specific quality indicators for monitoring and tracking the reasons for adverse appeal decisions. Maintain mediation records and reports using a tool that tracks all mediation/appeal requests, dates of the requests, number of requests completed and not completed, and outcomes. Must be able to accurately assess medical conditions and symptoms and functional abilities. Support analysis of the Mediation and Appeals process for quality improvement by maintaining information in database for tracking/trending all decisions, dates, issues and outcomes. Maintain professional relationships with provider community and external customers and identify opportunities for improvement. Communicate and coordinate with OAH and the Attorney General’s Office. Proactively anticipate and work to mitigate problems that could result in customer dissatisfaction or failure to deliver contracted services. Enter appeal results into QiRePort as applicable. Communicate with Mediations Centers to schedule mediations within timelines. Research cases in appeal to prepare for mediation to include PCG records as well as independent assessment(s), supporting docs and comm log notes within QiRePort. Assure contract compliance by meeting all contractual, legal, and regulatory requirements pertaining to this role - Meet expectations in Quality Assurance benchmarks - Meet expectations in Quality Control measures. Is knowledgeable of NC Medicaid Recipient Due Process Rights and Prior Approval Policies and Procedures in order to maintain appropriate systems for implementation. Work to negotiate settlements during mediations. Assist both CAP programs with maintaining SRF and MDT review compliance when needed. Perform other duties as assigned by management. 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 duties that management may deem necessary from time to time.