Clinical Reviewer - RN (Remote within Alabama)

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.

Utilizes 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.

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. 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. Abstracts review-related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review-related documents to appropriate parties. Performs ongoing reassessment of review process to offer opportunities for improvement and/or change. Fosters positive and professional relationships and acts as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process. Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review. Always maintains confidentiality through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies. Utilizes proper telephone etiquette and judicious use of other verbal communications, following Acentra Health policies, procedures, guidelines. Actively cross-trains to perform duties of other contracts within the Acentra Health network to provide a flexible workforce and meet client/consumer needs. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.