Behavioral Health UM Clinical Reviewer RN (Remote Within Virginia)

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 Behavioral Health UM Clinical Reviewer RN to join our growing team.

Job Summary:

Our Clinical Reviewer RN will use clinical expertise to review 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, and other regulatory standards.

*Position is remote but candidates must be located within the State of Virginia.

Job Responsibilities:

• Review and interpret patient records and compare against criteria to determine medical necessity and appropriateness of care; determine if the medical record documentation supports the need for services.
• Determine approval or initiate a referral to the physician consultant and process physician consultant decisions, ensuring the reason for the denial is described in sufficient detail in correspondence.
• Foster positive and professional relationships and liaise 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 maintaining and using current/updated information for review.
• Always maintain medical records confidentiality through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
• Utilize proper telephone etiquette and judicious use of other verbal and written communications, following Acentra Health policies, procedures, and guidelines.
• Actively cross-trains to perform duties of other contracts within the Acentra Health network to provide a flexible workforce to meet client/consumer needs.
• Other duties as assigned.

Why us?

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 nationwide. Our company cares about our employees, giving you the tools and encouragement, you need to achieve the finest work of your career.

Thank You!

We know your time is valuable, and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may interest you. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

Visit us at Acentra.com/careers/

EOE AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by applicable Federal, State, or Local law.

Requirements

Required Qualifications/Experience: 

• Active unrestricted Registered Nurse (RN) License in the State of Virginia.
• Strong clinical assessment and critical thinking skills.
• 1+ year of Utilization Review (UR) and/or Prior Authorization or related work experience.
• 3+ years of direct experience in a clinical setting or other applicable State clinical experience or license per contract requirements.
• Knowledge of InterQual OR ASAM guidelines.
• Ability to provide technical consultation and policy interpretation.
• Microsoft Office basic skills.

Preferred Qualifications/Experience: 

• Knowledge of current National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Committee (URAC) standards.
• Experience with Traumatic Brain Injury (TBI) and Psychiatric Residential Treatment Facility (PRTF).
• Experience with Applied Behavioral Analysis (ABA).

Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide additional protection, security, and support for your career and life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.  

Compensation

The pay range for this position is $21.64 - $36.06 per hour.

Based on our compensation philosophy, an applicant’s placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.