Clinical Reviewer-SCA

Acentra Health, LLC•UNAVAILABLE, UNAVAILABLE

About The Position

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. Job Summary: The Clinical Reviewer utilizes clinical expertise during beneficiary interaction in conjunction with contract requirements, critical thinking and utilizes decision-making skills to assist with communicating medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards.

Requirements

Bachelor’s Degree from an accredited college or university in a related field
Active, unrestricted LPN or RN license in the applicable state and/or a Compact State license.
2+ years of clinical experience in a hospital or post-acute environment required.
2+ years of experience working in call center environment
2 years of experience working with clinical assessments required
1 year Medical record abstracting experience required
1 year UR and/or Prior Authorization or related experience
Must be proficient in Microsoft Office and internet/web navigation

Nice To Haves

Excellent written and verbal communication skills
Some knowledge of Case Management, UR and/or Prior Authorization or related experience is preferred
Knowledge of the organization of medical records, medical terminology, and disease process required
Experience in behavioral health setting a plus
Bilingual (English/Spanish) a plus

Responsibilities

Assures accuracy and timeliness of all applicable review type cases within contract requirements
Assesses, evaluates, and addresses daily workload and call queues; adjusts work schedules daily to meet the workload demands of the department
In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and planning implementation of improvement areas
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 and contact/resource person for provider 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
Attend training and scheduled meetings and for maintenance and use of current/updated information for review
Cross trains and perform duties of other contracts to provide a 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