Clinical Reviewer - LPN/LVN/RN @ Acentra Health
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Job Details
Company Overview
Acentra Health empowers better health outcomes through technology, services, and clinical expertise. "Lead the Way" is our rallying cry, inviting you to embrace our mission, engage in problem-solving, and take ownership of your work.
Job Summary
The Clinical Reviewer - LPN/LVN/RN is responsible for reviewing medical records against criteria, contract requirements, and regulatory standards. You will employ critical thinking to determine medical appropriateness while meeting production and quality assurance standards.
Responsibilities
- Ensure accuracy and timeliness of all review cases within contract requirements.
- Assess and adjust workload daily to meet demands.
- Collaborate with supervisors for quality monitoring activities.
- Maintain current review process and clinical practice knowledge.
- Act as providers' liaison for customer service and problem resolution.
- Perform various review types as workload indicates and cross-train as needed.
- Adhere to corporate policies including HIPAA Privacy and Security Rules.
Work Schedule
Five 8-hour shifts with alternating weekends, 9:00 AM to 6:00 PM Eastern.
Qualifications
Required: Active, unrestricted LPN/LVN or RN license in Indiana or a Compact state clinical license; 3+ years clinical experience in acute, behavioral health, or med-surgical environment; 2+ years in Utilization Review/Management or Prior Authorization; 2+ years medical necessity review experience; 1+ years with InterQual or Milliman Care Guidelines; strong clinical assessment, critical thinking, and communication skills; proficiency with multiple systems; flexibility and organizational skills.
Preferred: Diploma/certificate in Practical Nursing for LPN/LVN, Associate/Diploma/Bachelor's degree for RN; knowledge of NCQA and URAC standards; team orientation; proficiency in Microsoft Office; strong time management and confidentiality with HIPAA compliance.
Why Us?
Join a team of experienced leaders, clinicians, and technologists dedicated to redefining healthcare expectations. Your work will improve lives nationwide and provide you with the tools to achieve excellence.
Key skills/competency
- Medical Record Review
- Clinical Assessment
- Utilization Review
- Regulatory Compliance
- InterQual/Milliman Care
- Critical Thinking
- HIPAA
- Team Collaboration
- Time Management
- Customer Service
How to Get Hired at Acentra Health
🎯 Tips for Getting Hired
- Customize Your Resume: Highlight clinical review and UR/UM experience.
- Research Acentra Health: Understand their mission and values.
- Tailor Your Application: Focus on regulatory and compliance skills.
- Prepare for the Interview: Practice case studies and process questions.