Clinical Reviewer - RN - Part-time (Remote U.S.)

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.

Acentra Health is looking for a Clinical Reviewer - RN - Part-time (Remote U.S.) to join our growing team.

Job Summary:

• As a Clinical Nurse Reviewer, utilize clinical expertise to assess 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 URAC and other regulatory benchmarks, ensuring precision and compliance in medical record reviews.

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.
• Determine approval or initiate a referral to the physician consultant and process physician consultant decisions, ensuring the reason for denial is described in sufficient detail on correspondence.
• Abstract review-related data/information accurately and prompt on an appropriate review tool using the appropriate means. Ensure accurate and timely submission of all administrative and review-related documents to the company.
• Perform ongoing reassessment of the review process to identify opportunities for improvement and/or change.
• Foster positive and professional relationships and act as a liaison with internal and external customers to ensure effective working relationships and team building, facilitating the review process.
• Be responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
• Maintain medical records confidentiality through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
• Utilize proper telephone etiquette and judicious use of other verbal and written communications, following company policies, procedures, and guidelines.
• Actively cross-train to perform duties of other contracts within the company network to provide a flexible workforce to meet client/consumer needs.
• Perform other duties as assigned.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

** Work Schedule: 20 hours / week for a minimum of four hours per day, Monday through Friday. **

Required Qualifications/Experience:

• Active, unrestricted Registered Nurse (RN) License in South Carolina, or an RN Compact State clinical license per contract requirements.
• Minimum of an Associate or Bachelor's Degree in Nursing.
• 2+ years of clinical experience in an acute or med-surgical environment.
• Knowledge of the organization of medical records, medical terminology, and disease processes.
• Strong clinical assessment and critical thinking skills.

Preferred Qualifications/Experience:

• Utilization Management (UM)/Utilization Review (UR) or Prior Authorization experience.
• Background in Behavioral Health, Surgery, and/or Durable Medical Equipment.
• Knowledge of InterQual criteria or Milliman Care Guidelines (MCG).
• Knowledge of current Utilization Review Accreditation Commission (URAC) standards.
• Medical record abstracting skills.
• Excellent verbal and written communication skills.
• Ability to work in a team environment.
• Flexibility and strong organizational skills.
• Must be proficient in Microsoft Office and internet/web navigation.

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Why us?

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.

We do this through our people.

You will have meaningful work that genuinely improves people's lives nationwide. Our company cares about our employees, giving you the tools and encouragement, you need to achieve the finest work of your career.

Thank You!

We know your time is valuable, and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may interest you. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

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Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. The benefits for this position include prorated Paid Time Off, participation in our 401(k) Plan, and EAP benefits.

Additionally, regular part-time employees are eligible for education assistance, with a maximum benefit per year. This program provides support for tuition and other expenses related to the pursuit of a degree, as well as Continuing Education Unit (CEU) and Continuing Medical Education (CME) courses that are job-related.

EEO AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

Compensation

The pay range for this position is listed below.

"Based on our compensation philosophy, an applicant's position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level."