Clinical Reviewer - RN - PRN (Remote U.S.)

Acentra Health, LLC•UNAVAILABLE, UNAVAILABLE

23h•Remote

About The Position

Acentra Health is looking for a Clinical Reviewer - RN - PRN (Remote U.S.) to join our growing team. This role involves reviewing medical records against established criteria, contract requirements, and regulatory standards. The Clinical Reviewer will use critical thinking to determine the medical appropriateness of care, while also meeting production goals and quality assurance standards. Ensuring that day-to-day processes align with NCQA, URAC, CMS, and other regulatory benchmarks is crucial for maintaining precision and compliance in medical record reviews.

Requirements

Active, unrestricted Registered Nurse (RN) License in South Carolina, 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 work experience in Utilization Review (UR), Utilization Management (UM), OR Prior Authorization.
1+ years of knowledge of InterQual criteria
Remote work experience

Nice To Haves

Knowledge of Utilization Review Accreditation Commission (URAC) standards.
Knowledge of Medicare (CMS) guidelines.
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.

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.
Initiate a referral to the physician consultant and process physician consultant decisions, ensuring the reason for denial is described in sufficient detail in correspondence.
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 to ensure effective working relationships and team building, facilitating the review process.
Be responsible for attending training and scheduled meetings and maintaining and using current/updated information for review.
Maintain medical records confidentiality by properly using computer passwords, maintaining secured files, and adhering 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.
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.