Lead Clinical Reviewer - Acentra Health : Job Details

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 Health is looking for a Lead Clinical Reviewer to join our growing team.

Job Summary:

The purpose of this position is to review medical records against appropriate criteria in conjunction with contract requirements to determine medical appropriateness. This position partners with Clinical Operations Manager with daily operations of the Virginia contract ensuring quality, productivity & compliance in accordance with contract deliverables. This position utilizes 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. They will ensure day-to-day processes are conducted in accordance with Virginia Business Rules, VAC, CMS, URAC, ERISA/DOL and ACA requirements/guidelines and timelines. They will perform quality monitoring/audits activities.

**This position is remote within the State of Virginia.

Responsibilities:

• Maintains a minimum of 75% of the required productivity requirements
• Guides team members in daily tasks
• Acts as subject matter expert
• Supports training and documentation
• May assist with escalations and quality checks

• First in line for questions prior to escalation to Clinical Operations Manager

• Responsible for the quality monitoring/audits activities including identifying areas of improvement, plan implementation of improvement areas, and staff training

• Under the direction/guidance of director/operations manager manages, reviews and reports outliers to establish timely quality improvement initiatives

• Assess and evaluate the daily work queues throughout the day to ensure cases are completed timely

• Assist and provide input to the Clinical Operations Manager (Clin Ops Manager) and Director with updating and creating job-aids as needed

• 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

• Supports Clin Ops Manager with determining approvals 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

• Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means Accurate and timely submission of all administrative and review related documents to appropriate parties

• Under the direction of the Ops Manager performs ongoing reassessment of review process to offer opportunities for improvement and/or change

• 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

• Always maintains medical records confidentiality 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 Health policies, procedures, and guidelines

• Actively cross-trains to perform duties of other contracts within the VA (DMAS) BH & Specialty Services network to provide a flexible workforce to meet client/consumer needs

• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rule

Required qualifications:

• Active and unrestricted license for the state of Virginia as a Mental Health Professional (LMHP) the same as defined in Physician, Licensed Clinical Psychologist, Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), Licensed Substance Abuse Treatment Practitioner, Licensed Marriage and Family Therapist (LMFT), Certified Psychiatric Clinical Nurse Specialist, License Behavior Analyst, Licensed Psychiatric/Mental Health Nurse Practitioner
• Master's degree from an accredited college with relevant degree program
• 2+ years of experience in Prior Authorization, Utilization Review (UR), or Utilization Management (UM)

Preferred qualifications:

• Ability to work alternating weekends
• Knowledge of CMS and InterQual criteria
• Knowledge of current NCQA/URAC standards
• Proficiency in Microsoft Office and internet/web navigation
• Knowledge of the organization of medical records, medical terminology, and disease process
• Strong clinical assessment and critical thinking skills
• Requires excellent written and verbal communication skills
• Medical record abstracting skills

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.

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.

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

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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.

Compensation

The pay 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.

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