Medicare/ACD Specialist (RN) - Remote

Medicare Clinical Reviewer (Action Code Database/Utilization Management) - RN

• Are you an experienced Clinical Reviewer looking for a new challenge?
• Do you value care management and quality improvement?
• Are you motivated, energetic, and excited to become part of the Acentra Health team?

If so, you might be our next new team member!

Who we need:

This position utilizes expertise in medical coding and knowledge of Medicare Coverage Guidelines to maintain an internal, client-specific prior authorization guidelines reference tool referred to as the action code database (ACD). Maintaining the database requires monitoring CMS transmittals and regulatory updates, reviewing internal prior authorization trends, and collaborating with the internal team, the client, and the client’s claims administrator. This position also serves as a member of the utilization management team and requires expertise in applying medical necessity criteria, critical thinking, and decision-making skills to determine medical appropriateness of requested services. Maintaining production goals, QA standards, and compliance with CMS, URAC, ERISA/DOL and ACA requirements/guidelines and timelines is critical part of the position.

Why us?

Acentra Health is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting.

People Focused. Mission Driven.

Shape the future of healthcare with us. We are mission driven to improve lives through healthcare quality and clinical expertise.

We do this through our people.

At Acentra Health, you can do meaningful work that makes a real difference for the lives of individuals across the country. We are an organization that cares deeply about our employees and we provide the training and support to do the best work of your career.

Benefits are a key component of your rewards package at Acentra Health. These benefits are designed to provide you and your family additional protection, security, and support for both your career and your life away from work. They are comprehensive and fit a variety of needs and situations. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more.

What you’ll do:

• Review and accurately interpret CMS medical necessity and prior authorization guidelines
• Maintain current knowledge of CMS regulations, guidance documents, and transmittals
• Maintain internal ACD spreadsheet and ACD database within Microsoft Access
• Schedule and host ACD meetings internally and with the client
• Review monthly CPT code report and make suggestions based on the data; review with the Manager prior to meetings
• Perform ongoing assessment and maintenance of codes within the ACD and update as appropriate, in collaboration with manager and client
• Review and interpret patient records and compare against criteria to determine medical necessity and appropriateness of care; determine if the medical record documentation supports the need for services.
• Approve medically necessary requests; refer those not meeting criteria to the physician reviewer; process physician decisions ensuring reason for the denial is described in sufficient detail on correspondence.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Kepro policies, procedures, and guidelines
• Actively cross-trains to perform duties of other roles within this contract to provide a flexible workforce to meet client/consumer needs.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

What you’ll need:

Required Qualifications

• Active, unrestricted Registered Nurse Compact State License.
• Graduation from an accredited Nursing Degree Program required.
• Certified Medical Coder; preferred

Knowledge, Skills, Abilities

• Knowledge of CMS medical necessity guidelines and benefit coverage criteria strongly preferred.
• Knowledge of current URAC standards preferred.
• Medical record abstraction skills r