Role Description Acentra Health is looking for a Clinical Reviewer - LPN/LVN or RN (remote U.S.) to join our growing team. The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements. Work Schedule: Five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays.

• Assures accuracy and timeliness of all applicable review type cases within contract requirements.
• Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
• In collaboration with Supervisor, 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.
• Attends training and scheduled meetings for current/updated information.
• Cross trains to provide 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.

Qualifications

• Active, unrestricted LPN/LVN or RN license in the state of Indiana or a Compact state clinical license.
• Associate's degree (bachelor's preferred) or Practical/Professional nursing diploma from an accredited nursing school, college, or university.
• 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience.
• 2+ years of medical necessity review experience.
• 1+ years of InterQual criteria and/or Milliman Care Guidelines (MCG) experience.
• Knowledge of medical records, medical terminology, and disease processes.
• Strong clinical assessment and critical thinking skills.
• Excellent written and verbal communication skills.
• Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively.
• Flexibility and strong organizational skills.
• Ability to work five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays.

Requirements

• 3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment.
• Knowledge of current National Committee for Quality Assurance (NCQA) standards.
• Knowledge of Utilization Review Accreditation Commission (URAC) standards.
• Ability to work in a team environment.
• Proficient in Microsoft Office.
• Efficient time management, including the ability to prioritize tasks, and meet deadlines.
• Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.

Benefits

• Comprehensive health plans.
• Paid time off.
• Retirement savings.
• Corporate wellness.
• Educational assistance.
• Corporate discounts.
• And more.

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