Clinical Reviewer-PRN

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.

• The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements.

• Ensures accuracy and timeliness of all applicable review type cases within contract requirements.
• Serves primarily as a service plan, plan of care (POC) reviewer for CAP/C and CAP/DA.
• Ensures all reviews are completed in alignment with clinical coverage policies, protocols, and guidelines, including accurate interpretation and application to case determinations.
• Drafts denial narratives and denial letters when recommended determinations result in an adverse decision.
• Meets daily productivity expectation of a minimum of 15 POC reviews per day.
• Conducts second-level POC reviews when necessary and adheres to established turnaround time expectations for RAIs, second-level reviews, and the drafting of denial narratives and letters.
• Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
• In collaboration with Supervisor and POC Team Lead, responsible for quality monitoring activities.
• Maintains current knowledge base related to review processes and clinical practices.
• Functions as providers' liaison for customer service issues and problem resolution.
• Performs all applicable review types as workload indicates.
• Fosters positive and professional relationships with internal and external customers.
• Participates in required training and scheduled meetings to remain current on updates and process changes.
• Cross-trains to provide flexible workforce to meet client/customer needs including service request forms (SRFs), Assessments, Multidisciplinary Team (MDT) Assessment Reviews, quality reviews, and providing training and knowledge transfer to other clinical staff on POC review processes to support continuity of operations and coverage.
• Provide cross-coverage and support for additional review queues as needed, including during periods of team member PTO or high-volume workload demands.
• 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.

Required Qualifications

• Active unrestricted RN license required.
• 1+ years' experience conducting plan of care (POC) reviews
• Knowledge of medical records, medical terminology, and disease processes required.
• Strong understanding of NC Medicaid policies, regulations, and reimbursement mechanisms, particularly related to long term services and support for children with disabilities.
• Strong clinical assessment and critical thinking skills required.
• Excellent written and verbal communication skills required.
• Ability to work independently, prioritize tasks, and manage multiple projects simultaneously in a fast-paced environment.

Preferred Qualifications

• Bachelor's Degree from an accredited college or university in a related field.
• Knowledge of NC healthcare system, Medicaid programs, and community resources.

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 employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.

We do this through our people.

You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.

Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

The pay range for this position is listed below.

Based on our compensation philosophy, an applicant's position…