Clinical Reviewer - SCA; RN​/LPN - Remote

Company Overview

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.

Acentra seeks a Clinical Reviewer to join our growing team.

Job Summary: The Clinical Reviewer utilizes clinical expertise during beneficiary interaction in conjunction with contract requirements, critical thinking and utilize 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.

Shift Information: This position requires availability to work between 12pm - 8:30pm EST for an 8‑hour shift and 10am - 8:30pm EST for a 10‑hour shift. This position may also require a weekend and holiday rotation.

• 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 plan 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
• Attends 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 Rules

The list of accountabilities is not intended to be all‑inclusive and may be expanded to include other education‑ and experience‑related duties that management may deem necessary from time to time.

• Active, unrestricted LPN or RN license in the applicable state and/or a Compact State license.
• Knowledge of the organization of medical records, medical terminology, and disease process required.
• Strong clinical assessment and critical thinking skills required.
• Medical record abstracting skills required.
• 2+ years of clinical experience in a hospital or post‑acute environment required.

• Minimum of one year UR and/or Prior Authorization or related experience.
• Requires excellent written and verbal communication skills.
• Must be proficient in Microsoft Office and internet/web navigation.
• Bachelor's Degree from an accredited college or university in a related field.
• Some knowledge of Case Management, UR and/or Prior Authorization or related experience is preferred.
• Experience in call center environment a plus.
• Experience in a behavioral health setting a plus.
• Bilingual (English/Spanish) a plus.

We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and…