Clinical Reviewer - RN (Remote U.S.)

Remote, USA Full-time Posted 2025-11-03

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Company Overview 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. Job Summary and Responsibilities Acentra Health is looking for a Clinical Reviewer - RN (Remote U.S.) to join our growing team. Job Summary: <ul><li>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, CMS, and other regulatory benchmarks, ensuring precision and compliance in medical record reviews.</li></ul>Responsibilities:<ul dir="auto"><li>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.</li><li>Initiate a referral to the physician consultant and process physician consultant decisions, ensuring the reason for denial is described in sufficient detail in correspondence.</li><li>Abstract review-related data/information accurately and promptly using the appropriate means on an appropriate review tool.</li><li>Ensure accurate and timely submission of all administrative and review-related documents to the company.</li><li>Perform ongoing reassessment of the review process to identify improvement and/or change opportunities.</li><li>Foster positive and professional relationships and liaise with internal and external customers to ensure effective working relationships and team building, facilitating the review process.</li><li>Be responsible for attending training and scheduled meetings and maintaining and using current/updated information for review.</li><li>Maintain medical records confidentiality by properly using computer passwords, maintaining secured files, and adhering to HIPAA policies.</li><li>Utilize proper telephone etiquette and judicious use of other verbal and written communications, following company policies, procedures, and guidelines.</li><li>Actively cross-train to perform duties of other contracts within the company network to provide a flexible workforce to meet client/consumer needs.</li><li>Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.</li></ul>The above list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary. Work Hours: * Monday through Friday, 8:00 AM until 5:00 PM within the Time Zone where you reside, plus? ** One day per week is a priority day that would be assigned to complete expedited cases received between 3:00 PM and 6:00 PM Central. Qualifications Required Qualifications/Experience:<ul dir="auto"><li>Active, unrestricted Registered Nurse (RN) License in any state, or an RN compact state License.</li><li>Completion of an Associate’s, Bachelor's or higher degree in Nursing (or Diploma).</li><li>2+ years of clinical experience in an acute OR med-surgical environment.</li><li>1+ years of work experience in Utilization Review (UR), Utilization Management (UM), OR Prior Authorization.</li><li>1+ years of knowledge of medical records, medical terminology, and disease process organization.</li><li>1+ years of knowledge of InterQual criteria and/or Milliman Care Guidelines (MCG).</li></ul>Preferred Qualifications/Experience:<ul dir="auto"><li>Knowledge of current National Committee for Quality Assurance (NCQA) standards.</li><li>Knowledge of Utilization Review Accreditation Commission (URAC) standards.</li><li>Knowledge of Medicare (CMS) guidelines.</li><li>Experience with Medical Appeals.</li><li>Experience with Medicare Advantage plans.</li><li>Medical Record Abstracting skills.</li><li>Clinical assessment and critical thinking skills.</li><li>Excellent verbal and written communication skills.</li><li>Ability to work in a team environment.</li><li>Flexibility and strong organizational skills.</li><li>Proficient in Microsoft Office and Internet/Web Navigation.</li></ul>#LI-SD1 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. 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. Thank You! 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 Visit us at <a style="color: #3598db;" title="https://careers.acentra.com/jobs" href="https://careers.acentra.com/jobs" target="_blank" rel="noopener" aria-label="Link Acentra Health">Acentra Health</a> EEO 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, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law. Benefits Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more. Compensation The pay range for this position is listed below. “Based on our compensation philosophy, an applicant’s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.” Pay Range USD $28.37 - USD $37.50 /Hr.

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