RN Utilization Management Reviewer - Remote & Must Reside within West 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.

Job Summary:

Acentra Health is seeking RN Utilization management reviewerr statewide in West Virginia for an exciting opportunity. As an RN Utilization Management Reviewer, you will be actively involved in pre-authorization reviews to determine medical necessity and providing recommendations to ensure members receive the services they need.

Job Responsibilities:

• Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care and 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 the reason for the denial is described in sufficient detail in correspondence.
• Fosters positive and professional relationships and acts as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
• Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
• 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 in all review areas to provide a flexible workforce to meet client/consumer needs.

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.

Required Qualifications/Experience:

• Must possess an active, unrestricted RN license in the State of West Virginia.
• Minimum of 2 year of experience in Utilization Review (UR), Prior Authorization, or related fields.
• Minimum of at least 5 years of direct experience in a clinical setting, or applicable State and/or Compact State clinical experience or license as per contract requirements.
• Familiarity with InterQual or ASAM criteria is nice to have.
• Strong clinical assessment and critical thinking abilities.
• Experience in completing retrospective reviews and long-term acute care hospital reviews.
• Ability to prioritize, assign, and follow up on tasks effectively.
• Ability to provide technical consultation, follw and understand local medical policies.
• Excellent communication skills for conveying information to individuals and groups through spoken, written, and email.
• Understanding of standards of practice related to determining Level of Care and standards of practice related to mental health, geriatrics, and other disorders.
• Experience with public mental health and medical programs, as well as public sector services and supports.
• Proficient with Microsoft Office applications, including Excel, Word, PowerPoint, Teams, Outlook, and other web-based software.
• Keen attention to detail, with the ability to prioritize and execute tasks efficiently and in a timely manner.

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 be of interest. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

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 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 compensation for this role is $67,000.00 - $69,000.00 base salary.

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.

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