Clinical Quality Reviewer

2 weeks ago

Harrisburg, Pennsylvania, United States Acentra Health Full time
Job Overview

Acentra Health is dedicated to enhancing health outcomes through innovative technology, services, and clinical knowledge. Our mission is to create health solutions that provide significant value and impact.

Position Summary:

Acentra Health is seeking a Clinical Reviewer who will leverage their clinical expertise to assess medical records against established criteria while adhering to contract stipulations. This role requires critical thinking and decision-making abilities to evaluate medical appropriateness, all while meeting production targets and quality assurance standards.

The Clinical Reviewer will ensure that daily operations comply with NCQA, URAC, CMS, and other regulatory guidelines. Flexibility in working hours is essential, including potential weekend and holiday shifts as dictated by contract requirements.

Key Responsibilities:

  • Evaluate and interpret patient medical records to ascertain the necessity and appropriateness of care, ensuring documentation supports service requirements.
  • Facilitate referrals to physician consultants and manage the communication of their decisions, ensuring clarity for beneficiaries.
  • Accurately and promptly document review-related data using the designated review tools, submitting all necessary administrative and review documents to relevant parties.
  • Continuously assess the review process to identify opportunities for enhancement.
  • Build and maintain professional relationships with both internal and external stakeholders to promote effective collaboration throughout the review process.
  • Participate in training sessions and meetings, ensuring access to current information for review purposes.
  • Uphold confidentiality of medical records by adhering to HIPAA regulations and employing secure practices.
  • Exhibit professional communication skills, both verbal and written, in line with company policies and guidelines.
  • Engage in cross-training to support various contracts within the Acentra network, ensuring a versatile workforce to meet client needs.

Why Choose Acentra Health?

We are a collective of skilled leaders, clinicians, and technology innovators committed to transforming the healthcare landscape. Our partnerships with state and federal agencies, providers, and employers are focused on ensuring improved healthcare and health outcomes.

At Acentra Health, you will engage in meaningful work that positively impacts lives across the nation. We prioritize our employees' well-being, equipping you with the resources and support necessary to excel in your career.

Benefits:

Our comprehensive benefits package is designed to offer protection, security, and support for both your professional and personal life. This includes health plans, paid time off, retirement savings options, wellness programs, educational assistance, and corporate discounts.

Equal Opportunity Employer:

Acentra Health is an Equal Opportunity Employer. All qualified candidates will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by applicable law.

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