Acentra Health · 10 hours ago
Clinical Reviewer-PRN
United States
Part-time
Remote
Entry Level
$0/hr - $0/hr
1+ years expAcentra Health is dedicated to empowering better health outcomes through innovative solutions and clinical expertise. They are seeking a Clinical Reviewer to utilize clinical expertise for reviewing medical records against criteria and contract requirements, ensuring accuracy and compliance in the review process.
Health Care
Responsibilities
Ensures accuracy and timeliness of all applicable review type cases within contract requirements
Serves primarily as a service plan, plan of care (POC) reviewer for CAP/C and CAP/DA
Ensures all reviews are completed in alignment with clinical coverage policies, protocols, and guidelines, including accurate interpretation and application to case determinations
Drafts denial narratives and denial letters when recommended determinations result in an adverse decision
Meets daily productivity expectation of a minimum of 15 POC reviews per day
Conducts second-level POC reviews when necessary and adheres to established turnaround time expectations for RAIs, second-level reviews, and the drafting of denial narratives and letters
Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department
In collaboration with Supervisor and POC Team Lead, responsible for quality monitoring activities
Maintains current knowledge base related to review processes and clinical practices
Functions as providers' liaison for customer service issues and problem resolution
Performs all applicable review types as workload indicates
Fosters positive and professional relationships with internal and external customers
Participates in required training and scheduled meetings to remain current on updates and process changes
Cross-trains provide flexible workforce to meet client/customer needs to include but not limited to service request forms (SRFs), Assessments, Multidisciplinary Team (MDT) Assessment Reviews, quality reviews, and providing training and knowledge transfer to other clinical staff on POC review processes to support continuity of operations and coverage
Provide cross-coverage and support for additional review queues as needed, including during periods of team member PTO or high-volume workload demands
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules
Qualification
Required
Active unrestricted RN license required
1+ years' experience conducting plan of care (POC) reviews
Knowledge of medical records, medical terminology, and disease processes required
Strong understanding of NC Medicaid policies, regulations, and reimbursement mechanisms, particularly related to long term services and support for children with disabilities
Strong clinical assessment and critical thinking skills required
Excellent written and verbal communication skills required
Ability to work independently, prioritize tasks, and manage multiple projects simultaneously in a fast-paced environment
Preferred
Bachelor's Degree from an accredited college or university in a related field
Knowledge of NC healthcare system, Medicaid programs, and community resources
Benefits
Comprehensive health plans
Paid time off
Retirement savings
Corporate wellness
Educational assistance
Corporate discounts
Company
Acentra Health
Acentra Health is a provider of clinical services and technological solutions to government healthcare organizations.
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
unknown2022-11-09Acquired
Leadership Team
Todd Stottlemyer
Chief Executive Officer
Grant Christie
Senior Vice President, Market Strategy and Solutions
Recent News
2026-02-04
2026-01-13
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