UM Reviewer & Appeals Coordinator RN/LCSW (Remote within Virginia)

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 UM Reviewer & Appeals Coordinator RN/LCSW (Remote within Virginia) to join our growing team.

Job Summary:

This position is focused on Waiver Services and functions in a blended role as a clinical reviewer and appeals coordinator. In the clinical reviewer role – you will utilize 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. In the appeals coordinator role -researches, investigates, and assists in resolving complaints and appeals. Documents results of the complaints and appeals and the dispositions at all levels, including notification to all required parties. Generates all acknowledgement letters and ensures they are sent out with in specified timeframe. Completes all determinations within the contractual standard timeframe. 

*Position is remote, but must reside within the State of Virginia. Must be able to travel on the rare chance of an in-person appeal. 

Job Responsibilities: 

In this role, you will play a pivotal role in managing and coordinating the clinical appeals process with our client.

UM Clinical Reviewer:

• Using clinical knowledge and nursing experience, to review and interpret 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.  
• 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.
• Maintains current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit's business and uses clinical judgment in their application.
• Dedicated to meeting the expectations and requirements of internal and external customers.

Appeals Coordinator:

• Reviewing clinical information for appeals to determine the need for requested services.
• Responsible for triaging, investigating, and resolving complex appeals related to clinical matters, ensuring adherence to regulatory guidelines, and organizational standards.
• Testifying and representing Acentra Health during State Fair Appeals Hearings.
• Generates tailored written correspondence, including acknowledgment letters, to customers such as members, providers, and regulatory agencies.
• Resolves cases within mandated timeframes as per compliance with turnaround compliance.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

Requirements

Required Qualifications/Experience: 

• Active Registered Nurse (RN) license or a Compact License or a Licensed Clinical Social Worker (LCSW) license to practice in the Commonwealth of Virginia.
• 2+ years of experience in healthcare/managed care, preferably with experience in Utilization Management and/or Quality Management
• Ability to review cases to determine the appropriate level of appeal.
• The ability to multitask between working within a Reviewer queue, completing appeals, and testifying at hearings.
• Skilled in conducting thorough research to investigate and resolve the outcomes of complaints.
• Prior experience in healthcare/managed care appeals
• Experience with Medicaid program regulations.
• Experience with clinical review process, including how to analyze and research clinical issues.
• Demonstrated excellence in customer service.
• Ability to meet and uphold departmental standards, including adherence to timelines and quality benchmarks.
• Basic data entry skills.

Preferred Qualifications/Experience:  

• 3+ years of clinical experience in an acute or med-surgical environment.
• Previous experience with medical appeals processes.
• Healthcare industry or government health and human service program Knowledge of InterQual OR ASAM criteria.
• Knowledge of current National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Committee (URAC) standards.

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.

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.

Benefits

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 $36.00-38.00 per hour.

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