Clinical Reviewer - RN (Remote U.S.)

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 - RN (Remote U.S.) to join our growing team. Job Summary: Review medical records against criteria, contract requirements, and regulatory standards. Employ critical thinking to determine medical appropriateness while meeting production goals and QA standards. Ensure day-to-day processes align with NCQA, URAC, CMS, and other regulatory benchmarks, ensuring precision and compliance in medical record reviews.

Review and interpret patient records, comparing them against criteria to determine medical necessity and appropriateness of care; assess if the medical record documentation supports the need for services. Initiate a referral to the physician consultant and process physician consultant decisions, ensuring the reason for denial is described in sufficient detail in correspondence. Abstract review-related data/information accurately and promptly using the appropriate means on an appropriate review tool. Ensure accurate and timely submission of all administrative and review-related documents to the company. Perform ongoing reassessment of the review process to identify improvement and/or change opportunities. Foster positive and professional relationships and liaise with internal and external customers to ensure effective working relationships and team building, facilitating the review process. Be responsible for attending training and scheduled meetings and maintaining and using current/updated information for review. Maintain medical records confidentiality by properly using computer passwords, maintaining secured files, and adhering to HIPAA policies. Utilize proper telephone etiquette and judicious use of other verbal and written communications, following company policies, procedures, and guidelines. Actively cross-train to perform duties of other contracts within the company network to provide a flexible workforce to meet client/consumer needs. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules. The above list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary.