Description
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.
Job Summary and Responsibilities
Job Summary
The Clinical Reviewer utilizes clinical expertise during beneficiary interaction in conjunction with contract requirements, critical thinking and utilize decision-making skills to assist with communicating medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards. Shift hours will be 11:00am to 8:00pm EST.
Job Responsibilities
- Assures accuracy and timeliness of all applicable review type cases within contract requirements.
- Assesses, evaluates, and addresses daily workload and call 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.
Qualifications
Required Qualifications/Experience
- Active unrestricted LPN, RN or, Social Worker or other applicable State and/or Compact State clinical license.
- Knowledge of the organization of medical records, medical terminology, and disease process required.
- Strong clinical assessment and critical thinking skills required.
- Requires excellent written and verbal communication skills.
- Medical record abstracting skills required.
- Must be able to work a schedule of 11:00am to 8:00pm EST.
Preferred Qualifications/Experience
- Bachelor’s Degree from an accredited college or university in a related field.
- Some knowledge of Case Management, UR and/or Prior Authorization or related experience is preferred.
- Experience in call center environment a plus.
- Experience in a behavioral health setting a plus.
- Bilingual (English/Spanish) a plus.