Clinical Reviewer-PRN (RN)

Job Summary and Responsibilities

The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements.

• Accurately and timely review medical records within contract requirements.
• Evaluate and address daily workload and queues; adjust work schedules daily to meet demands.
• Maintain current knowledge of review processes and clinical practices.
• Act as a provider's liaison for customer service issues and problem resolution.
• Perform all applicable review types as workload indicates.
• Foster positive and professional relationships with internal and external customers.
• Attend training and scheduled meetings for current/updated information.
• Function as a provider's liaison for customer service issues and problem resolution.
• Ensure adherence to all corporate policies, including HIPAA and Privacy and Security Rules.

Qualifications

• Active, unrestricted Registered Nurse (RN) License in any state, or an RN compact state.
• A minimum of 2+ years of clinical experience in an acute OR med-surgical environment.
• Knowledge of medical records, medical terminology, and disease process organization.
• Skilled in reviewing, interpreting, and abstracting data from medical records.
• Strong clinical assessment and critical thinking skills.
• Excellent verbal and written communication skills.
• Proficient in Microsoft Office and internet/web navigation.

Preferred Qualifications/Experience

• Bachelor's Degree from an accredited college or university in a related field.
• Knowledge of current National Committee for Quality Assurance (NCQA) standards.
• Knowledge of Utilization Review Accreditation Commission (URAC) standards.
• Knowledge of Independent Review Organization (IRO).
• Knowledge of Medicare (CMS) guidelines.
• Experience with Medical Appeals.
• Ability to work in a team environment.
• Flexibility and strong organizational skills.

Benefits

• Access to the Acentra Health 401(k) Plan with company match.
• Employee Assistance Program (EAP) resources.
• Participation in wellness and employee discount programs.