Clinical Reviewer - LPN/LVN or RN (Remote U.S.)

Acentra Health, LLC

106d • $28 - $36

About The Position

Acentra Health is looking for a Clinical Reviewer - LPN/LVN or RN (Remote U.S.) to join our growing team. The role involves reviewing medical records against criteria, contract requirements, and regulatory standards. The Clinical Reviewer will employ critical thinking to determine medical appropriateness while meeting production goals and QA standards. The position ensures that day-to-day processes align with regulatory benchmarks, ensuring precision and compliance in medical record reviews.

Requirements

• Active, unrestricted LPN/LVN or RN license in the state of Indiana or a Compact state clinical license, per contract requirements.
• 3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment.
• 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization.
• 2+ years of knowledge of medical necessity review experience.
• 1+ years of knowledge of InterQual criteria and/or Milliman Care Guidelines (MCG).
• Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively.
• Strong clinical assessment and critical thinking skills.
• Excellent written and verbal communication skills.
• Flexibility and strong organizational skills.

Nice To Haves

• A minimum of a diploma or certificate in Practical Nursing for an LPN/LVN.
• An Associate, Diploma or Bachelor's degree from an accredited college or university in a related field for an RN.
• Knowledge of current National Committee for Quality Assurance (NCQA) standards.
• Knowledge of Utilization Review Accreditation Commission (URAC) standards.
• Ability to work in a team environment.
• Proficient in Microsoft Office.
• Efficient time management, including the ability to prioritize tasks, and meet deadlines.
• Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.

Responsibilities

• Assures accuracy and timeliness of all applicable review type cases within contract requirements.
• Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
• In collaboration with Supervisor, responsible for quality monitoring activities.
• 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 for 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 for current/updated information.
• Cross trains and perform duties to provide flexible workforce to meet client/customer needs.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree