Acentra seeks a Utilization Clinical Reviewer to join our growing team in California.
Job Summary
As a Utilization Clinical Reviewer, you'll harness your expertise to evaluate medical records against precise criteria, wielding critical thinking and decisive skills to appraise the medical necessity of psychiatric inpatient care. With a focus on meeting production targets and maintaining top-tier quality assurance standards, this role serves as the linchpin for ensuring the accuracy and consistency of the Psychiatric Inpatient Concurrent Review process in alignment with the California Mental Health Services Authority (CAMHSA).
Adhering to standards set by NCQA, URAC, and other regulatory bodies, you'll play a pivotal role in upholding industry benchmarks. This full-time Clinical Reviewer Remote position is based in the state of California. This provides an opportunity for impactful work without requiring direct patient interaction or communication.
A California LCSW/LMFT/LPCC/LCPC License is Required. The selected candidate must reside and work in California.
Job Responsibilities:
- Review and interpret patient records against established criteria to determine medical necessity and care appropriateness, ensuring documentation supports service requirements.
- Determine approval or initiate referrals to the physician consultant, processing decisions and providing detailed denials as needed.
- Accurately and timely abstract review-related data onto appropriate review tools and submit all administrative documents to relevant parties.
- Continuously reassess review processes for improvement opportunities and facilitate changes as necessary.
- Foster positive relationships, acting as a liaison with internal/external stakeholders to facilitate the review process and maintain professionalism.
- Attend training and meetings, and maintain updated information for review purposes.
- Ensure medical record confidentiality by adhering to HIPAA policies and maintaining proper computer security measures.
- Utilize proper communication etiquette and adhere to Acentra Health policies in verbal and written interactions.
The 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, Skills and Experience:
- Minimum 2 years of experience managing or working with Medicaid, government health plans, or hospital programs is required.
- Active California License is Required in one of the following; LCSW/LMFT/LPCC/LCPC.
- Graduation from an accredited Master's Degree Program.
- Knowledge of the Parity in Mental Health and Substance Use Disorder Services Final Rule (Parity Rule; Title 42 of the CFR, part 438.910).
- Familiarity with psychiatric disorders and standards of practice related to determining the Level of Care and mental health assessments.
- Knowledge and understanding of public sector services and supports.
- Proficiency in Microsoft Excel, Word, PowerPoint, Teams, and Outlook.
- Ability to diagnose clinically while accounting for psychological and behavioral issues.
- Proficient with computer equipment and web-based software for conducting work.
- Detail-oriented with effective prioritization and task execution abilities.
- Proficiency in psychological, emotional, behavioral, and physical function assessment and analysis.
- Understanding of Medicaid programs with experience navigating similar projects.
- Ability to develop level-of-care recommendations based on clinical medical records and evaluations.
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 $37.00 per hour to $41.00 per hour.
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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