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 mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. 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 is looking for a Nurse (RN) Clinical Reviewer to join our growing team.

Job Summary:

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.

***Position is full-time remote as long as you have an active unrestricted RN license in the State of North Dakota or a compact state license. The operating hours are Monday-Friday, 8:00am-5:00pm EST/CST.***

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. 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. Foster positive and professional relationships and act 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, adherence to HIPAA polices. Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Acentra 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. Other duties as assigned.