Nurse Clinical Reviewer Position
2 days ago
CNSI and Kepro have merged to form Acentra Health, a company dedicated to delivering innovative health solutions that drive maximum value and impact.
Our mission is to empower better health outcomes through technology, services, and clinical expertise. We strive to innovate and lead the way in healthcare solutions.
Job Summary:We are seeking a skilled Nurse (RN) Clinical Reviewer to join our team. As a Clinical Reviewer, you will utilize your clinical expertise to review medical records against established criteria, applying critical thinking and decision-making skills to determine medical appropriateness.
You will ensure that day-to-day processes align with NCQA, URAC, and other regulatory standards, maintaining production goals and QA standards.
Responsibilities:- Review and interpret patient records, comparing them against criteria to determine medical necessity and appropriateness of care.
- Determine approval or initiate a referral to the physician consultant, processing decisions and ensuring reason for denial is described in sufficient detail.
- Foster positive relationships with internal and external customers, acting as a liaison to ensure effective working relationships and team building.
- Maintain medical records confidentiality, adhering to HIPAA policies and utilizing proper telephone etiquette.
- Actively cross-train to perform duties of other contracts within the Acentra network, providing a flexible workforce to meet client/consumer needs.
- Active unrestricted RN license in the State of North Dakota or a compact state license.
- 1+ years of Utilization experience Review (UM) and/or Prior Authorization or related experience.
- 3+ years of direct experience in a clinical setting or other applicable State and/or Compact State clinical experience.
- Knowledge of InterQual or American Society of Addiction Medicine (ASAM) guidelines.
- Strong clinical assessment and critical thinking skills.
- Knowledge of current National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Commission (URAC) standards.
- Ability to prioritize, assign, and follow up on work.
- Ability to problem solve.
- Ability to provide technical consultation and policy interpretation.
- Excellent customer service.
- Excellent written and verbal communication skills.
- Microsoft Office basic skills.
Acentra Health offers a comprehensive benefits package, including comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.
We are a company that cares about our employees, providing them with the tools and encouragement needed to achieve their best work.
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