Description
CNSI and Kepro are now Acentra Health! 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.
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. May be required to work additional hours as required by contract, work volume, and as requested by Kepro leadership.
Job Responsibilities
- 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.
- 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.
- Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
- Maintains medical records confidentiality at all times 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 and written communications, following Acentra policies, procedures, and guidelines.
- Actively cross-trains to perform duties of other contracts within the Acentra network to provide a flexible workforce to meet client/consumer needs.
Requirements
- Associate or Bachelor Degree.
- Active unrestricted LPN, RN, Social Worker or other applicable State and/or Compact State clinical license per contract requirements.
- Minimum two years of clinical experience in an acute or med-surgical environment required.
Preferred Qualifications/Experience
- Minimum of one year UR and/or Prior Authorization or related experience strongly preferred.
- Direct behavioral/mental health experience in a clinical setting or other applicable State and/or Compact State clinical experience or license per contract requirements.