• Responsible for supporting and assisting all cardiology administrative and clinical utilization management and quality improvement functions • Act as a clinical liaison to providers, clients, and patients • Maintain and operate Guideline Directed Medial Therapy • Communicate clinical information needs to ordering providers • Prep cases for P2P discussions • Coordinate with UM staff for communication of clinical decisions • Complete UM projects and participate in site visit reviews • Serve as subject matter expert in assigned meetings

• Perform medical claim reviews for claims requiring preauthorization or appeals • Determine medical necessity and appropriateness for coverage and reimbursement • Document medical rationale for payment or denial of services • Educate staff on medical reviews, coverage determinations, and coding procedures • Participate in quality control activities

• Manages and supports quality and performance improvement by assisting staff to implement strategies that identify, prioritize, measure, and improve key clinical processes and outcomes • Reviews patient records to determine the complete, accurate, and timely documentation of all conditions that support home health/hospice care and treatment of the patient • Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care • Consults with providers, management, and operations to ensure consistency within the application of clinical criteria • Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements • Maintains current knowledge of clinical indicators and compliance requirements • Manages tools to collect outcome data and provides regular feedback to individuals, managers, and leaders • Provides concurrent medical record review to assess documentation compliance • Facilitates recommended interventions • Reviews deficiencies in documentation with involved staff and facilitates corrective action • Participates in the ongoing development and implementation of an established performance improvement plan • Reviews orders for data entry, completeness, and appropriateness for admission to home health/hospice services • Promotes, obtains, and reviews appropriate documentation for any home health/hospice specific quality data

Role Description Acentra Health is looking for a Clinical Reviewer (LPN, LVN, RN) to join our growing team. The purpose of this position is to review medical records against appropriate criteria in conjunction with contract requirements to determine medical appropriateness. This is a remote position. The selected candidate will typically work Monday-Friday from 8:00 AM – 5:00 PM Eastern AND from 10:00 AM - 7:00 PM Eastern one day, every other week, as assigned. - 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 quality monitoring activities, including identifying areas of improvement and plan implementation of improvement areas. - Maintains current knowledgebase related to review processes and clinical practices related to the review processes, functions as the internal resource to nurse reviewers regarding all review process questions and/or concerns. - Functions as provider 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 liaises with internal and external customers to ensure effective working relationships and team building to facilitate the review process. - Attends training and scheduled meetings for maintenance and use of current/updated information for review. - Cross-trains and performs 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 duties that management may deem necessary. Qualifications - Active, unrestricted Licensed Practical Nurse (LPN) license, Licensed Vocational Nurse (LVN) license, or Registered Nurse (RN) license from the state where you reside, per contract/state requirements. - Associate's degree or practical/vocational nursing diploma or nursing certificate program, in accordance with state requirements. - Medical record abstracting skills, including knowledge of medical record organization, medical terminology, and disease processes. - Strong clinical assessment and critical thinking skills. - Will typically work Monday-Friday from 8:00 AM – 5:00 PM Eastern AND from 10:00 AM - 7:00 PM Eastern one day, every other week, as assigned. Requirements - Bachelor's Degree from an accredited college or university in a related field. - 1+ years Utilization Management/Utilization Review. - 1+ years Private Duty Nursing OR Home Health experience. - Excellent written and verbal communication skills. Benefits - Comprehensive health plans. - Paid time off. - Retirement savings. - Corporate wellness. - Educational assistance. - Corporate discounts. - And more. Company Description 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. 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. We do this through our people. You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.