Clinical Reviewer

Acentra Health, LLC•UNAVAILABLE, Arkansas

10h•Remote

About The Position

Acentra Health is seeking a Clinical Reviewer to use clinical expertise to review medical records against appropriate criteria and contract requirements. The role completes prior authorization, continued stay, retroactive, retrospective quality, and other applicable reviews for inpatient and outpatient behavioral health providers. It evaluates service documentation for quality and compliance with Arkansas Medicaid regulations and refers cases to a Physician Reviewer for medical necessity determinations when appropriate. The Clinical Reviewer collaborates with the Clinical Director, Team Supervisor, and Medical Director to monitor provider trends and program utilization, support quality monitoring, and recommend internal policies, procedures, and processes. The position also serves as a resource and liaison for behavioral health providers, including providing education about reconsideration and appeals and assisting with program-specific education and training. The reviewer manages daily workloads and queues to meet contract requirements, maintains current knowledge of review processes and clinical practices, cross-trains as needed, and builds professional relationships with internal and external customers. The role requires protecting client privacy and confidentiality and following corporate policies, including HIPAA, as well as applicable ethical, legal, accreditation, and regulatory standards. This is a fully remote position; the employee must reside and work in Arkansas. Travel is not required. The stated pay range is USD $28.37–$39.19 per hour.

Requirements

Active, unrestricted Arkansas licensure in good standing in Social Work, Counseling, or Psychology through the applicable Arkansas licensing board; accepted credentials include LCSW, LMSW, LAMFT, LMFT, LAC, LPC, LPE, or LPE-I.
Master’s degree in Behavioral Health or a related field from an accredited college or university.
At least 2 years of experience in a behavioral health setting conducting utilization reviews or behavioral health case management.
Ability to handle confidential HIPAA information with discretion.
Skill interfacing with multiple providers across various settings.
Strong knowledge of medical, psychiatric, and psychological terminology; mental health assessment tools and treatment plans; and behavioral health services across acute inpatient, outpatient, home, and community settings.
Familiarity with government-funded behavioral health programs, including their policies and procedures.
Strong interpersonal skills to build rapport with physicians, behavioral health providers, and family members.
Highly responsible, self-motivated, detail-oriented, and able to demonstrate strong listening, verbal, and written communication skills.
Solid clinical skills for assessing services through clinical record reviews.
Must reside and work in Arkansas.

Nice To Haves

Experience with child and adolescent behavior.
Utilization Review (UR) and Utilization Management (UM) experience in behavioral health or medical settings.
Clinical quality review experience, including evaluation of medical records.
Familiarity with medical necessity review criteria specific to Arkansas Medicaid.
In-depth knowledge of Arkansas Medicaid behavioral health policies and procedures.
Proficiency with automated review systems and Microsoft Office Suite.

Responsibilities

Complete prior authorization, continued stay, retroactive, retrospective quality, and other applicable reviews for inpatient and outpatient behavioral health providers.
Assure accuracy and timeliness of applicable review cases within contract requirements.
Assess and manage daily workloads and queues, adjusting work schedules to meet department workload demands.
Participate in quality monitoring activities in collaboration with the Supervisor.
Maintain current knowledge of review processes and clinical practices.
Monitor provider trends and review utilization activities for government-funded behavioral health programs in collaboration with clinical leadership.
Collaborate with the Team Supervisor and Medical Director on medical necessity determinations.
Evaluate the quality and regulatory compliance of service documentation in client records, including compliance with Arkansas Medicaid regulations.
Refer cases to the Physician Reviewer for medical necessity determinations when appropriate.
Serve as a resource and liaison for Behavioral Health providers throughout the review process.
Provide education to Behavioral Health providers on the Reconsideration and Appeal process, and assist with program-specific education and training.
Recommend internal policies, procedures, and processes in collaboration with clinical leadership.
Foster positive and professional relationships with internal and external customers.
Attend training and scheduled meetings and cross-train to meet client and customer needs.
Maintain client privacy, confidentiality, and safety; adhere to corporate policies, including HIPAA Privacy and Security Rules, and applicable ethical, legal, accreditation, and regulatory standards.