CAP Clinical POC Reviewer

Acentra Health, LLC•UNAVAILABLE, UNAVAILABLE

About The Position

Acentra Health is looking for a CAP Clinical POC Reviewer to join their growing team. The position utilizes clinical expertise to review, evaluate, and process Home and Community-Based Services (HCBS) waiver requests, Plans of Care, reassessments, medical records, and related documentation against applicable clinical criteria, Medicaid policies, waiver requirements, contractual obligations, and program standards.

Requirements

Active, unrestricted Registered Nurse license in a Compact state.
Minimum of two years of relevant experience in clinical services, case management, utilization management, healthcare, critical thinking, legal requirements, or healthcare policies and procedures.
Demonstrated knowledge and skills equivalent to advanced-level practice.
Knowledge of medical records, medical terminology, and disease processes.
Excellent written and verbal communication skills.
Ability to work independently, prioritize tasks, and manage multiple projects simultaneously in a fast-paced environment.

Nice To Haves

Master's Degree from an accredited college or university in a related field.
Experience working in a regulated environment.
Knowledge of and experience reviewing and participating in legal claims or polices from a clinical perspective.
Proficiency with Microsoft Office applications and other systems required to perform assigned responsibilities.
Ability to establish and maintain positive working relationships with internal and external stakeholders.
Ability to communicate concerns and recommendations professionally.
Ability to collaborate effectively in a team environment.

Responsibilities

Conducts clinical reviews of service plans/Plans of Care (POC) and other assigned review types in accordance with contract requirements, regulatory standards, and clinical guidelines.
Ensures timely, accurate, and compliant case determinations, including the preparation of denial determinations and related correspondence when applicable.
Meets established productivity, quality, and turnaround time expectations.
Performs second-level reviews and supports quality monitoring activities as assigned.
Monitors and prioritizes workload to ensure service levels and departmental objectives are met.
Serves as a clinical resource and liaison to internal and external stakeholders, supporting issue resolution and customer service needs.
Maintains current knowledge of review processes, clinical practices, regulatory requirements, and program updates through ongoing training and development.
Collaborates with leadership and team members to support operational goals, process improvement initiatives, and continuity of operations.
Provides cross-training and cross-coverage across review functions, including support for other review queues, quality activities, and staff education as needed.
Builds and maintains positive, professional relationships with internal and external customers.
Complies with all corporate policies, including HIPAA Privacy and Security requirements.
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.