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