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 Clinical Reviewer to join our growing team.

Job Summary:

Review medical records against criteria, contract requirements, and regulatory standards. Employ critical thinking to determine medical appropriateness while meeting production goals and QA standards. Ensure day-to-day processes align with NCQA, URAC, and other regulatory benchmarks, ensuring precision and compliance in medical record reviews.

Job Responsibilities:

Review and interpret patient records, comparing them against criteria to determine medical necessity and appropriateness of care; assess if the medical record documentation supports the need for services. Initiate a referral to the physician consultant and process physician consultant decisions, ensuring the reason for denial is described in sufficient detail on correspondence. Abstract review-related data/information accurately and prompt on an appropriate review tool using the appropriate means. Ensure accurate and timely submission of all administrative and review-related documents to the company. Perform ongoing reassessment of the review process to identify opportunities for improvement and/or change. Foster positive and professional relationships and act as a liaison with internal and external customers to ensure effective working relationships and team building, facilitating the review process. Be responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review. 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 company policies, procedures, and guidelines. Actively cross-train to perform duties of other contracts within the company network to provide a flexible workforce to meet client/consumer needs. Perform other duties as assigned.