Clinical Utilization Reviewer

Acentra Health is seeking a skilled Clinical Reviewer to join our growing team in California.

As a Utilization Clinical Reviewer, you will leverage your expertise to meticulously assess medical records against established criteria. Using critical thinking and sound judgment, you will evaluate the medical necessity of psychiatric inpatient care to ensure appropriate utilization of services. This role is pivotal in maintaining the accuracy and consistency of the Psychiatric Inpatient Concurrent Review process, aligned with the California Mental Health Services Authority (CAMHSA) and guided by NCQA, URAC, and other regulatory standards. This is a full-time remote position requiring residence and active licensure in California, offering you an opportunity to make a meaningful impact without direct patient contact.

A current California LCSW, LMFT, LPCC, or LCPC license is required. Candidates must reside in and work from California.

Key Responsibilities

• Medical Record Review: Evaluate patient records to determine medical necessity and care appropriateness, ensuring documentation complies with established service requirements.
• Decision-Making: Approve services or refer cases to physician consultants, providing detailed denial rationales as necessary.
• Data Documentation: Accurately and promptly document review-related data and submit administrative paperwork to the appropriate parties.
• Process Improvement: Identify opportunities to enhance the review process and collaborate with stakeholders to implement changes.
• Collaboration and Communication: Act as a liaison with internal and external stakeholders, fostering positive relationships and ensuring a smooth review process.
• Professional Development: Participate in training sessions and meetings to stay informed about updates relevant to the review process.
• Compliance and Confidentiality: Uphold medical record confidentiality by adhering to HIPAA policies and utilizing secure systems.
• Policy Adherence: Maintain professionalism and follow Acentra Health's communication standards in all verbal and written interactions.

This list of accountabilities is not exhaustive and may include additional duties as assigned by management.

Required Qualifications And Experience

• Minimum of 2 years managing or working with Medicaid, government health plans, or hospital programs.
• Active California licensure as an LCSW, LMFT, LPCC, or LCPC.
• Master's degree from an accredited program in social work, counseling, or a related field.
• Strong understanding of psychiatric disorders, Level of Care determination, and mental health assessments.
• Familiarity with Parity in Mental Health and Substance Use Disorder Services and public sector service systems.
• Skilled in Microsoft Excel, Word, PowerPoint, Teams, and Outlook; adept at using computer equipment and web-based software.
• Ability to assess psychological, emotional, behavioral, and physical functioning, and provide evidence-based recommendations.
• Strong organizational skills with the ability to prioritize tasks and meet deadlines.
• Experience navigating Medicaid programs or similar government health systems.
• Demonstrated 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 $39.00 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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