Clinical Assessor (RN - Appeals and Mediations)

Following a 2022 merger of CNSI and Kepro, Acentra Health combines clinical services, technology solutions, and data analytics to accelerate better health outcomes.
This is a great time to join our team of passionate individuals working together to pursue the most effective solutions to today’s complex healthcare challenges.
Our culture is fueled by passion and driven by purpose.
Clinical Assessor (Appeals and Mediations) Are you an experienced Clinical Assessor looking for a new challenge? Are you looking to join a team that ensures a collaborative and inviting culture where everyone can thrive? If so, you might be our next new team member! Who we need: The Clinical Assessor travels to perform education and initial/re-evaluation assessments of Aged and Disabled Waiver members for the purposes of determining program medical eligibility.
Provides education to applicants/members and conducts the Pre-Admission Screening assessment.
Manages a caseload of assigned members to ensure that assessments are scheduled, appropriate persons are in attendance, assessments are performed and data is entered into the APS CareConnection© within prescribed timelines.
Travel to homes and facilities within the catchment area Must be able to accurately assess medical conditions and symptoms and functional abilities 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.
Singularly Focused.
Mission Driven.
Accelerating Better Outcomes is our Mantra! We are mission-driven to innovate health solutions that deliver maximum value and impact.
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.
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.
What you’ll do: Conducts mediations at the request of beneficiaries who have had an adverse decision for all programs.
and compliance.
Identifies and documents specific quality indicators for monitoring and tracking the reasons for adverse appeal decisions.
Maintains mediation records and reports using a database that tracks all mediation/appeal requests, dates of the requests, number of requests completed and not completed, and outcomes (Atrezzo) Supports analysis of the Mediation and Appeals process for quality improvement by maintaining information in database for tracking/trending all decisions, dates, issues and outcomes Duties related to maintenance of internal databases Performs other duties as assigned by management Proactively anticipates and works to mitigate problems that could result in customer dissatisfaction or failure to deliver contracted services Enters Results of Mediation assessment requests into QiReport as applicable Enters appeal results into QiReport as applicable Communicates with Mediations Centers to schedule mediations within timelines.
Researches cases in appeal to prepare for mediation to include PCG records as well as independent assessment(s), supporting docs and comm log notes within QiReport Assures contract compliance by meeting all contractual, legal, and regulatory requirements pertaining to this role - Meets expectations in Quality Assurance benchmarks - Meets expectations in Quality Control measures Is knowledgeable of NC Medicaid Recipient Due Process Rights and Prior Approval Policies and Procedures in order maintain appropriate systems for implementation Works to negotiate settlements during mediations 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.
What you’ll need: Required Qualifications Active and current driver’s license required; BSN preferred CCM preferred and/or required per contract requirements Associate’s Degree or Bachelor’s Degree Program Active unrestricted RN, Social Worker, Counselors or other applicable State and/or Compact State clinical license and/or certifications.
Knowledge, Skills, Abilities Knowledge of the ADW program policies and procedures Experience 2+ years’ experience with working with NC DHB ( Medicaid) to manage Mediation and Appeal for Beneficiaries 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.