Utilization Clinical Reviewer - Remote (Must Reside in California)

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.

Acentra Health is looking for a Clinical Reviewer to join our growing team.

As a Utilization Clinical Reviewer, you'll harness your expertise to evaluate medical records against precise criteria, applying critical thinking and decisive skills to assess 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 a key driver in ensuring the accuracy and consistency of the Psychiatric Inpatient Concurrent Review process, in alignment with the standards set by the California Mental Health Services Authority (CalMHSA).

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.

• 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, process decisions, and provide 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 both verbal and written interactions.

• This list of responsibilities is not intended to be all-inclusive and may be modified or expanded at management's discretion.

• Minimum of 2 years of experience working with Medicaid, government-funded health plans, or hospital-based programs.

• Active, unrestricted California license in one of the following: LCSW, LMFT, LPCC, or LCPC.

• Master's degree from an accredited program in Social Work, Counseling, Psychology, or a related behavioral health field.

• In-depth knowledge of the Mental Health Parity and Addiction Equity Act and the Substance Use Disorder Services Final Rule.

• Strong understanding of psychiatric disorders and clinical standards related to Level of Care determinations and mental health assessments.

• Proven ability to develop accurate level-of-care recommendations based on clinical documentation and medical record evaluations.

• Clinical expertise in diagnosing psychological and behavioral conditions, with the ability to consider complex co-occurring factors.

• Skilled in conducting comprehensive assessments across psychological, emotional, behavioral, and physical health domains.

• Highly detail-oriented with strong time management, task prioritization, and execution abilities in a fast-paced environment.

• Proficient in Microsoft Office Suite, including Excel, Word, PowerPoint, Teams, and Outlook.

• Familiarity with public-sector healthcare systems and community-based support services.

• Strong working knowledge of Medicaid programs, including experience managing or supporting related healthcare initiatives.

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.

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.

Compensation

The compensation for this role is $40.00 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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