Company Overview 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. Job Summary and Responsibilities Acentra Health is looking for a Clinical Reviewer to join our growing team. Job Summary: The Clinical Reviewer utilizes clinical expertise during beneficiary interaction in conjunction with contract requirements, critical thinking and utilize decision-making skills to assist with communicating medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards. Shift hours will be 11:00am to 8:00pm EST. Responsibilities: - Assures accuracy and timeliness of all applicable review type cases within contract requirements - Assesses, evaluates, and addresses daily workload and call 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 Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time. Qualifications Required Qualifications - Active unrestricted LPN, RN or, Social Worker or other applicable State and/or Compact State clinical license - Knowledge of the organization of medical records, medical terminology, and disease process required - Strong clinical assessment and critical thinking skills required - Requires excellent written and verbal communication skills - Medical record abstracting skills required - Must be able to work a schedule of 11:00am to 8:00pm EST Preferred Qualifications - Bachelor’s Degree from an accredited college or university in a related field - Some knowledge of Case Management, UR and/or Prior Authorization or related experience is preferred - Experience in call center environment a plus - Experience in a behavioral health setting a plus - Bilingual (English/Spanish) a plus 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 https://careers.acentra.com/jobs 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 below: “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.” Pay Range USD $28.37 - USD $32.00 /Hr.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The CERIS Professional Review Nurse provides analysis of medical services to determine appropriateness of charges on multiple types of medical bills and review of medical reports to determine appropriateness of medical care. Clinical and/or technical expertise is utilized to address the provision of medical care and to identify inappropriate billing practices and errors inclusive of, but not limited to: - Duplicate billing - Unbundling of charges - Services not rendered - Mathematical and data entry errors - Undocumented services - Reusable instrumentation - Unused services and supplies - Unrelated and/or separated charges - Quantity and time increment discrepancies - Inconsistencies with diagnosis - Treatment frequency and duration of care - DRG validation - Service/treatment vs. scope of discipline - Use of appropriate billing protocols This is a remote position. Qualifications - Must maintain current licensure as a Registered Nurse in the state of employment with a minimum of 4 years clinical experience - A minimum of an Associate Degree in Nursing is preferred - Thorough knowledge of both C.P.T. and I.C.D.10 codes is preferred - Medical bill auditing experience preferred - Experience in the clinical areas of O.R., I.C.U., C.C.U., E.R., and orthopedics preferred - Prospective, concurrent and retrospective utilization review experience preferred Requirements - Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and/or direct reporting manager - Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans - Completely document work and final conclusions in designated computer program - Adhere to regular and consistent work attendance - Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP) and other requirements as outlined in the Employee Handbook - Responsive to additional Professional Review job duties as assigned by management or determined by legislative changes and/or market changes Benefits - Medical (HDHP) w/Pharmacy - Dental - Vision - Long Term Disability - Health Savings Account - Flexible Spending Account Options - Life Insurance - Accident Insurance - Critical Illness Insurance - Pre-paid Legal Insurance - Parking and Transit FSA accounts - 401K - ROTH 401K - Paid time off Company Description CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!). CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Centene is seeking a Clinical Review Nurse to join our Arizona Medicaid team in a fully remote role. Position Overview: The ideal candidate will have experience with prior authorizations for outpatient services and be available to work Arizona hours, Monday through Friday, 8:00 AM – 5:00 PM. Qualifications: - Active RN or LPN license in Arizona or a multistate compact license. - Candidates located in New Mexico, Nevada, Washington, or Oregon will be considered if they hold an active Arizona license. Prior authorization experience with outpatient services preferred. - Strong clinical assessment and communication skills. - Ability to work Arizona business hours remotely. Join Centene and help us deliver high-quality care and support to our Medicaid members across Arizona. Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. - Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria - Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care - Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member - Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care - Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities - Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines - Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members - Provides feedback on opportunities to improve the authorization review process for members - Performs other duties as assigned - Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: - LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Opportunity Overview: We are looking for Doctors of Physical Therapy (DPT) who have expertise in Physical Therapy to deliver on Cohere’s musculoskeletal and orthopedic programs by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. Reporting to the Medical Director MSK Spine and Ortho for Cohere Health, and part of the review team that includes non-clinical intake specialists and nurses. This is a fast-paced environment that favors people who are able to learn quickly, be hands-on, handle ambiguity, and communicate effectively with people of different backgrounds and perspectives. What you’ll do: - Provide timely medical reviews that meet Cohere’s stringent quality parameters - Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen - Clearly and accurately document all communication and decision-making in Cohere workflow tools, ensuring a member and provider can easily reference and understand your decision - Use correct templates for documenting decisions during case review - Meet the appropriate turn-around times for clinical reviews - Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research - Demonstrate the highest level of professionalism, accountability, and service in your interactions with Cohere teammates and providers - Support projects specific to building the team's clinical expertise and efficiency, as delegated - Support the team on operational improvements and member/provider experience involving clinical review tasks, as delegated What you’ll need: - Doctor of Physical Therapy (DPT) from a CAPTE-accredited physical therapy program - Active, unrestricted Physical Therapist license in the state of practice (or eligibility for licensure) - 5+ years of direct clinical patient care experience - Familiarity with facilities rendering care in PT, OT, SLP - 1+ years of managed care utilization review experience, preferably in an utilization management organization within a Medicare, Commercial or Medicaid payor organization preferred - Membership in national and/or regional specialty societies preferred Pay & Perks: 💻 Fully remote opportunity with about 5% travel 🩺 Medical, dental, vision, life, disability insurance, and Employee Assistance Program 📈 401K retirement plan with company match; flexible spending and health savings account 🏝️ Up to 184 hours (23 days) of PTO per year + company holidays 👶 Up to 14 weeks of paid parental leave 🐶 Pet insurance  The salary range for this position is $95,000 to $105,000 annually; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment. Interview Process*: - Connect with Talent Acquisition for a Preliminary Phone Screening - Meet your Hiring Manager! - Behavioral Interview(s) *Subject to change About Cohere Health: Cohere Health’s clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. Cohere Health works with over 660,000 providers and handles over 12 million prior authorization requests annually. Its responsible AI auto-approves up to 90% of requests for millions of health plan members. With the acquisition of ZignaAI, we’ve further enhanced our platform by launching our Payment Integrity Suite, anchored by Cohere Validate™, an AI-driven clinical and coding validation solution that operates in near real-time. By unifying pre-service authorization data with post-service claims validation, we’re creating a transparent healthcare ecosystem that reduces waste, improves payer-provider collaboration and patient outcomes, and ensures providers are paid promptly and accurately. Cohere Health’s innovations continue to receive industry wide recognition. We’ve been named to the 2025 Inc. 5000 list and in the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022-2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. Backed by leading investors such as Deerfield Management, Define Ventures, Flare Capital Partners, Longitude Capital, and Polaris Partners, Cohere Health drives more transparent, streamlined healthcare processes, helping patients receive faster, more appropriate care and higher-quality outcomes. The Coherenauts, as we call ourselves, who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone. We can’t wait to learn more about you and meet you at Cohere Health! Equal Opportunity Statement: Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal. #LI-Remote #BI-Remote