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 mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. 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 is looking for a Clinical Review Specialist to join our growing team.

Job Summary:

The purpose of this position is to review medical records, prepare cases for physician review and perform related activities for selected cases on a timely, accurate and efficient basis. This selected candidate will prepare reports and other documentation for medical necessity reviews with special attention to State and managed care contractor (MCC) policies.

Job Responsibilities:

Perform required non-physician review activities within specified timeframes and within contractual guidelines. Communicate (verbally and/or in writing) 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 Insertion of the appropriate State Medicaid Office Reference Manual criteria and/or State Medicaid Clinical Criteria based on the appealed service(s) and specific to the enrollee’s population eligibility Monitor review requests for inconsistencies requiring a return, request for clarification from appropriate State Medicaid department, or communication with appropriate State Medicaid department. Returns, clarifications, and communications must follow established processes. Communicate with Acentra Health Administrative staff regarding returns, clarifications, and communications with TN Medicaid departments via established processes. Monitor MRU Outstanding MNRs Report multiple times daily to be aware of the current state of deliverables and plan workload accordingly. 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 Maintain open lines of communication with other Nurses, Reviewers, Acentra Health