Utilization Management (UM) Nurse Clinical Reviewer - LPN/RN (Remote U.S.)

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 company’s mission, actively engage in problem-solving, and take ownership of your work daily. 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 seeks a Utilization Management (UM) Nurse Clinical Reviewer - LPN/RN (Remote U.S.) to join our growing team.

Job Summary:

The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements, critical thinking, and decision- making skills to determine medical appropriateness.

Job Responsibilities:

• Performs all applicable review types as workload indicates accurately and timely. These may include both inpatient and outpatient review types.
• 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.
• Performs all applicable review types as workload indicates, accurately and timely. These may include both inpatient and outpatient review types.
• 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.
• Assures accuracy and timeliness of all applicable review type cases within contract requirements.
• Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.
• In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas.
• Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns.
• Functions as providers’ liaison and contact/resource person for provider customer service issues and problem resolution.
• Performs all applicable review types as workload indicates.
• Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
• Attends training and scheduled meetings and for maintenance and use of current/updated information for review.
• Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs.

Requirements

Required Qualifications/Experience:

• Active unrestricted Indiana Licensed Practical Nurse (LPN) OR Registered Nurse (RN) OR other applicable State and/or Compact State clinical license per contract requirements.
• Graduate of an accredited Diploma, Associate, or Bachelor’s Degree Nursing Program.
• 2+ years of Utilization Management (UM) experience from the State, Hospital, or Health Plan. 
• Knowledge of InterQual or MCG (Milliman) criteria.
• Knowledge of current NCQA/URAC standards.
• 2+ years of relevant clinical experience.
• Knowledge of the organization of medical records, medical terminology, and disease process.
• Strong clinical assessment and critical thinking skills required. Medical record abstracting skills required. 
• Must be proficient in MS Office and internet/web navigation.

Preferred Qualifications/Experience

• Experience with State Medicaid programs.

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 nationwide. Our company cares about our employees, giving you the tools and encouragement you need to achieve the finest work of your career.

Benefits are a key component of your rewards package. Our benefits are designed to provide additional protection, security, and support for your career and 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 $58,240-$74,880 annually.

“Based on our compensation program, an applicant’s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.” 

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 interest you. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

Visit us at Acentra.com/careers/

EOE 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, gender identity, national origin, disability, status as a protected veteran, or any other status protected by applicable Federal, State, or Local law.https://acentra.com/careers