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 Utilization Management (UM) Nurse Clinical Reviewer - LPN/RN (Remote U.S.) to join our growing team.
Job Summary:
The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements, critical thinking, and decision- making skills to determine medical appropriateness.
Job Responsibilities:
Performs all applicable review types as workload indicates accurately and timely. These may include both inpatient and outpatient review types. 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. Performs all applicable review types as workload indicates, accurately and timely. These may include both inpatient and outpatient review types. Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence. Assures accuracy and timeliness of all applicable review type cases within contract requirements. Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department. In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas. Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns. Functions as providers’ liaison and contact/resource person for provider customer service issues and problem resolution. Performs all applicable review types as workload indicates. 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. Attends training and scheduled meetings and for maintenance and use of current/updated information for review. Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs.