Clinical Reviewer

3 weeks ago

Harrisburg, United States Acentra Health Full time

CNSI and Kepro are now Acentra Health 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 company's mission, actively engage in problem-solving, and take ownership of your work daily. 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:

Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision-making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC, CMS, and other regulatory standards. Position is required to be available to work any hours under the contract's Scope of Work, including rotating weekends and holidays. Candidate may be required to work additional hours as required by contract, work volume, and as directed by Kepro leadership.

*Position is remote*

Job Responsibilities:

  • Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services
  • Initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for outcome is described in sufficient detail on correspondence at a level the beneficiary can understand
  • Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties
  • Performs ongoing reassessment of review process to offer opportunities for improvement and/or change
  • 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
  • Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review
  • Always maintains medical records confidentiality through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices
  • Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following KEPRO policies, procedures, and guidelines
  • Actively cross-trains to perform duties of other contracts within the Acentra network to provide a flexible workforce to meet client/consumer needs
Why us?

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 nationwide. Our company cares about our employees, giving 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 additional protection, security, and support for your career and life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

Thank You

We know your time is valuable, and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may interest you. Best of luck in your search

~ The Acentra Health Talent Acquisition Team

Visit us at Acentra.com/careers/

Requirements
  • Active unrestricted LPN or RN State and/or Compact State license per contract requirements
  • Graduation from an accredited Technical, Diploma, Associate or Bachelor Degree Nursing Program
  • Minimum two years of clinical experience in an acute , med-surgical, post-acute or rehabilitation environment required
  • Minimum of one year UR and/or Prior Authorization or related experience
  • Must be proficient in computer skills including Microsoft Office and internet/web navigation
  • Knowledge of current NCQA/URAC standards

Benefits

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

Compensation

The pay range for this position is $22.56 - $33.00

"Based on our compensation philosophy, an applicant's placement in the pay range will depend on various considerations, such as years of applicable experience and skill level."

EOE AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by applicable Federal, State, or Local law.

  • Clinical Reviewer

    4 weeks ago

    Harrisburg, Pennsylvania, United States Acentra Health Full time

    Acentra Health is a leading provider of health care services, and we are seeking a skilled Clinical Reviewer to join our team.As a Clinical Reviewer, you will play a critical role in ensuring the quality and integrity of our health care services. Your primary responsibility will be to review medical records and determine medical necessity and appropriateness...

  • Clinical Reviewer

    4 weeks ago

    Harrisburg, Pennsylvania, United States Acentra Health Full time

    Acentra Health is seeking a skilled Clinical Reviewer to join our team. As a Clinical Reviewer, you will play a critical role in ensuring the quality and accuracy of medical records. Your expertise will be utilized to review medical records against established criteria, utilizing your clinical knowledge and critical thinking skills to determine medical...

  • Clinical Review Nurse Sr

    2 weeks ago

    Harrisburg, United States Elevance Health Full time

    Clinical Review Nurse Sr. National Government Services is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs. Location: This is a virtual position and preferred candidates reside within 50 miles of an...

  • Clinical Reviewer

    3 weeks ago

    Harrisburg, United States CNSI Full time

    Description CNSI and Kepro are now Acentra Health 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 company's...

  • Clinical Care Coordinator

    4 weeks ago

    Harrisburg, Pennsylvania, United States UPMC Full time

    Care Manager Job DescriptionThe Care Manager at UPMC is responsible for coordinating the clinical and financial plan for patients. This involves performing overall utilization management, resource management, discharge planning, and post-acute care referrals and authorizations. The Care Manager works with a multi-disciplinary team in resource management,...

  • Clinical Utilization Manager

    3 weeks ago

    Harrisburg, Pennsylvania, United States UPMC Full time

    Job Summary:UPMC is seeking a skilled Clinical Utilization Manager to coordinate clinical and financial plans for patients. This is a full-time, day shift position with rotating weekend and holiday schedule.Main Responsibilities:• Reviews medical records daily to ensure patients continue to meet Level of Care (LOC) requirements and chart documentation...

  • Clinical Utilization Management Specialist

    4 weeks ago

    Harrisburg, Pennsylvania, United States CVS Health Full time

    About the Role:CVS Health is seeking a skilled Utilization Management Nurse Consultant to join our team. As a Utilization Management Nurse Consultant, you will play a critical role in coordinating, documenting, and communicating all aspects of the utilization/benefit management program.Key Responsibilities:Utilize clinical skills to coordinate, document, and...

  • Clinical Care Supervisor

    3 weeks ago

    Harrisburg, United States Angels of Care Pediatric Home Health Full time

    Join our team as a Clinical Care Supervisor with a Registered Nurse (RN) license for a growing company that has a huge HEART! Work with passionate, talented professionals that are dedicated to serving our clients and feel rewarded knowing that your job MATTERS!Angels of Care Pediatric Home Health is a family, clinically owned company that has been caring for...

  • Clinical Nurse Leader

    1 month ago

    Harrisburg, Pennsylvania, United States PennState Health Full time

    Penn State Health: A Leader in HealthcarePenn State Health is a multi-hospital health system serving patients and communities across 29 counties of Pennsylvania. Our mission is to improve health through patient care, research, education, and community outreach.About the RoleWe are seeking a highly skilled Registered Nurse to join our team as a Clinical Staff...

  • Traveling Clinical Pharmacist Opportunity

    2 days ago

    Harrisburg, Pennsylvania, United States ALOIS Healthcare Full time

    ALOIS Healthcare is seeking a travel clinical pharmacist to fill a 13-week position in Pennsylvania.About the PositionDuration: 13 weeksHours: 36 hours per weekShift: 12-hour daysThis role involves working as a retail pharmacist, reviewing prescriptions, compounding medications, and dispensing prescribed drugs according to regulatory requirements. The...

  • Pharmacy Technician

    1 month ago

    Harrisburg, Pennsylvania, United States CVS Health Full time

    Job SummaryCVS Health is seeking a highly skilled Pharmacy Technician to join our team in a non-clinical diversion role. As a Pharmacy Technician - Non-Clinical Diverts, you will play a critical role in ensuring the accuracy and integrity of prescription orders, while also contributing to the prevention of diversion and misuse of medications.Key...

  • Care Manager

    4 weeks ago

    Harrisburg, Pennsylvania, United States UPMC Full time

    Job Summary:UPMC is seeking a Part-time Care Manager to coordinate the clinical and financial plan for patients. This role involves overall utilization management, resource management, discharge planning, and post-acute care referrals and authorizations.Responsibilities:Reviews medical records daily to ensure patients continue to meet LOC requirements and...

  • Clinical Pharmacist Specialist-Internal Medicine

    2 weeks ago

    Harrisburg, United States UPMC - Pittsburgh Medical Center Full time

    Job DescriptionClinical Pharmacist Specialists work as part of a patient care team, focusing on safe and effective medication management for specialized patient populations. They provide direct patient-centered care, collaborate with interdisciplinary teams, and ensure clinical pharmacy services are integrated into the care process. Their responsibilities...

  • Clinical Pharmacist Specialist-Internal Medicine

    2 weeks ago

    Harrisburg, United States UPMC - Pittsburgh Medical Center Full time

    Job Description Clinical Pharmacist Specialists work as part of a patient care team, focusing on safe and effective medication management for specialized patient populations. They provide direct patient-centered care, collaborate with interdisciplinary teams, and ensure clinical pharmacy services are integrated into the care process. Their responsibilities...

  • Clinical Pharmacist Specialist-Internal Medicine

    3 weeks ago

    Harrisburg, United States UPMC - Pittsburgh Medical Center Full time

    Job DescriptionClinical Pharmacist Specialists work as part of a patient care team, focusing on safe and effective medication management for specialized patient populations. They provide direct patient-centered care, collaborate with interdisciplinary teams, and ensure clinical pharmacy services are integrated into the care process. Their responsibilities...

  • Nurse Practitioner, Clinical Advisor

    1 month ago

    Harrisburg, United States UnitedHealth Group Full time

    Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs – helping patients access and navigate care anytime and anywhere. As a team...

  • Pharmacy Technician

    4 weeks ago

    Harrisburg, Pennsylvania, United States CVS Health Full time

    Job SummaryThis is an exciting opportunity for Pharmacy Technicians to excel in a complex, team-oriented environment while developing and strengthening technical skills and pharmacology knowledge. The Non-Clinical Divert technician is responsible for screening orders, specializing in research, review and entry of prescription overrides. Basic knowledge and...

  • Clinical Pharmacist Specialist-Oncology Expert

    4 weeks ago

    Harrisburg, Pennsylvania, United States UPMC Full time

    Job SummaryClinical Pharmacist Specialists play a vital role in patient care teams, focusing on safe and effective medication management for specialized patient populations.They provide direct patient-centered care, collaborate with interdisciplinary teams, and ensure clinical pharmacy services are integrated into the care process.Key responsibilities...

  • RN Sanction Specialist

    4 weeks ago

    Harrisburg, Pennsylvania, United States CNSI Full time

    Acentra Health seeks a skilled RN Sanction Specialist to oversee the CMS Sanction process and ensure compliance with EMTALA regulations.Key Responsibilities:Maintain lines of communication between BFCC QIO and healthcare providersProduce written Initial and Final Sanction Notices and EMTALA communicationsMaintain case files with supporting...

  • Clinical Staff Leader

    4 weeks ago

    Harrisburg, Pennsylvania, United States PennState Health Full time

    Penn State Health is seeking a skilled Registered Nurse to join our team in Harrisburg, Pennsylvania.Job Summary:The Registered Nurse Clinical Staff Leader will be responsible for ensuring the delivery of high-quality patient care and optimal patient outcomes in our Behavioral Health Inpatient Acute Care unit.Responsibilities:Provide clinical patient care...