KEPRO UM Clinical Reviewer IP Rehab /IP Retro/ OP Rehab (REMOTE) in Richmond, Virginia
Following a 2022 merger of CNSI and Kepro, Acentra Health combines clinical services, technology solutions, and data analytics to accelerate better health outcomes. This is a great time to join our team of passionate individuals working together to pursue the most effective solutions to todays complex healthcare challenges. Our culture is fueled by passion and driven by purpose. 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. Singularly Focused. Mission Driven. Accelerating Better Outcomes is our Mantra! We are mission-driven to innovate health solutions that deliver maximum value and impact. We do this through our People. You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career. Benefits are a key component of your rewards package. Our benefits are designed to provide you additional protection, security, and support for both your career and your life away from work. We offer competitive salaries/pay, fantastic benefits including comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more. Position Overview Our Nurse Clinical Reviewer will use 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, and other regulatory standards. Role Responsibilities In this role, you will Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care and determines if the medical record documentation supports the need for services. Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring the reason for the denial is described in sufficient detail in correspondence. Fosters positive and professional relationships and acts as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process. Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review. Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies. Utilizes 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. Basic Qualifications To thrive in this role, you should have the following Active unrestricted RN license in the State of Virginia or a compact state license. Strong clinical assessment and critical thinking skills. Minimum 1 - 2 years Utilization Review (UR) 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 or license per contract requirements. Knowledge of InterQual or ASAM guidelines. Excellent customer service and problem solving skills. Ability to prioritize, assign, and follow up on work. Ability to provide technical consultation and policy interpretation. Excellent written and verbal communication skills. Strong Microsoft Office skills. Preferred Qualifications / Experience Knowledge of InterQual or ASAM criteria. Knowledge of current NCQA/URAC standards. Experience in completing retrospective reviews and long-term acute care hospital reviews. 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 be of interest. Best of luck in your search! The Acentra Health Talent Acquisition Team 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 Benefits Health insurance Paid time off Tuition reimbursement Source link Apply Job!