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. We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes. You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.
Clinical Reviewer - RN
Location
United States
Posted
5 days ago
Salary
$28 - $39 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
Role Description
Acentra Health is looking for a Clinical Reviewer - RN (Remote U.S.) to join our growing team.
- 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.
Responsibilities:
- 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.
- 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.
- Be responsible for attending training and scheduled meetings and maintaining current/updated information for review.
- Maintain medical records confidentiality by properly using computer passwords and adhering to HIPAA policies.
- Utilize proper telephone etiquette and judicious use of other verbal and written communications.
- Actively cross-train to perform duties of other contracts within the company network.
- Read, understand, and adhere to all corporate policies including those related to HIPAA.
- The above list of responsibilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary.
Work Hours:
- Must work, Monday through Friday, 8:00 AM until 5:00 PM in Eastern Time Zone hours.
Qualifications
- Active, unrestricted Registered Nurse (RN) License in any state, OR an RN compact state license.
- Associate’s, Bachelor's degree (or Diploma) in Nursing.
- 2+ years of clinical experience in an acute OR med-surgical environment.
- 1+ years of knowledge of medical records, medical terminology, and disease process organization.
Requirements
- 1+ years of work experience in Utilization Review (UR), Utilization Management (UM), OR Prior Authorization.
- Knowledge of current National Committee for Quality Assurance (NCQA) standards.
- 1+ years of knowledge of InterQual criteria and/or Milliman Care Guidelines (MCG).
- Knowledge of Utilization Review Accreditation Commission (URAC) standards.
- Medical Record Abstracting skills.
- Clinical assessment and critical thinking skills.
- Excellent verbal and written communication skills.
- Ability to work in a team environment.
- Flexibility and strong organizational skills.
- Proficient in Microsoft Office and Internet/Web Navigation.
Benefits
- Comprehensive health plans.
- Paid time off.
- Retirement savings.
- Corporate wellness.
- Educational assistance.
- Corporate discounts.
- And more.
Job Requirements
- Active, unrestricted Registered Nurse (RN) License in any state, OR an RN compact state license.
- Associate’s, Bachelor's degree (or Diploma) in Nursing.
- 2+ years of clinical experience in an acute OR med-surgical environment.
- 1+ years of knowledge of medical records, medical terminology, and disease process organization.
- 1+ years of work experience in Utilization Review (UR), Utilization Management (UM), OR Prior Authorization.
- Knowledge of current National Committee for Quality Assurance (NCQA) standards.
- 1+ years of knowledge of InterQual criteria and/or Milliman Care Guidelines (MCG).
- Knowledge of Utilization Review Accreditation Commission (URAC) standards.
- Medical Record Abstracting skills.
- Clinical assessment and critical thinking skills.
- Excellent verbal and written communication skills.
- Ability to work in a team environment.
- Flexibility and strong organizational skills.
- Proficient in Microsoft Office and Internet/Web Navigation.
Benefits
- Comprehensive health plans.
- Paid time off.
- Retirement savings.
- Corporate wellness.
- Educational assistance.
- Corporate discounts.
- And more.
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