Clinical Review Specialist

5 days ago

Nashville, Tennessee, United States CNSI Full time
Job Summary:

The Clinical Review Specialist will be responsible for reviewing medical records, preparing cases for physician review, and performing related activities in a timely, accurate, and efficient manner. This position will prepare reports and other documentation for medical necessity reviews, with a focus on State and managed care contractor (MCC) policies.

Key Responsibilities:
  • Perform required non-physician review activities within specified timeframes and within contractual guidelines.
  • Communicate with external customers to furnish information pertaining to the review process and results.
  • Contract-specific formatting of each medical necessity review, including the statement of the appealed services and citation of State Medicaid Rules.
  • Monitor review requests for inconsistencies requiring a return, request for clarification from the appropriate State Medicaid department, or communication with the appropriate State Medicaid department.
  • Edit assigned written medical necessity reviews within the TN Medicaid contract.
  • Collaborate directly with Reviewers regarding review quality issues or errors within each medical necessity review.
  • Formal completion of all medical necessity reviews following established processes.
  • Collaborate with Acentra Health Administrative staff and Medical Director regarding changes in processes to increase efficiency and quality.
  • Assist the Medical Director in communications with the appropriate TN Medicaid staff regarding quality concerns related to the MCCs, as needed.
  • Assist the Clinical Review Specialist II to perform and manage medical necessity review training and hearing witness training for all Reviewers.
  • Support quarterly quality assurance activities as needed.
Requirements:
  • RN active professional licensure required.
  • Recent nursing or medical records experience.
  • Utilization Review/Quality Assurance and coding experience helpful.
  • Training in continuous quality improvement approaches and methods a plus.
  • Must be able to live in or around Tennessee.
Preferred Qualifications:
  • Master's level degree in a related field desirable.
  • Excellent verbal communication skills, courteous and patient demeanor.
  • Must be customer-oriented and able to maintain composure under potentially stressful situations.
  • Good grammar, punctuation, spelling, and written communication skills.
  • Customer-focused, results-oriented, and capable of building and maintaining relationships with internal and external customers.
  • Must be flexible and able to work as a team member and support team decisions.
  • General knowledge of a PC-based computer system.
  • Knowledge of various software packages with the ability to learn additional software applications as needed.
  • Must be able to multi-task and prioritize assignments.
  • Must have good organizational skills and work independently.
Why Choose Acentra Health?

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:

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 $80,000 to $90,000 per year.

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