Clinical Reviewer (Remote - SCA - 25 Hrs/Wk)

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 purpose of this position is to utilize clinical expertise during beneficiary interaction and determine appropriateness for advocacy intervention in conjunction with contract requirements, critical thinking and utilize decision-making skills to assist with communicating determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards.

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 the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns Functions as providers’ liaison and contact/resource person for provider customer service issues and problem resolution Performs all applicable review types as workload indicates Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process Attends training and scheduled meetings and for maintenance and use of current/updated information for review Cross trains and perform duties of other contracts to provide a 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.