Medical Reviewer (Remote in Tennessee)

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.

Medical Reviewer

• Are you an experienced Medical Reviewer 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!

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 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:

• Prepare independent reviews of medical services appeals

• Review records, prepare and submit all reviews in keeping with the TennCare/Acentra Health contractual due dates. These may include appeals by TennCare members, CoverKids, members, Department of Intellectual & Developmental Disabilities clients, and Department of Commerce & Insurance appeals from TennCare providers.
• Critically evaluate the application of guidelines and protocols by the TennCare managed care organizations, dental benefits manager, and pharmacy benefits manager to the individual enrollee’s appeal. Take into consideration TennCare Rules of Medical Necessity, standards of care, evidence-based medicine, and hierarchy of evidence.
• Review relevant peer reviewed research and evidence-based sources as needed
• Edit Medical Necessity Reviews authored by other reviewers

• Provide expert medical witness testimony for the State in appeals hearings and consult with the assigned TennCare attorney prior to the hearing as needed
• Participate in quality assurance activities for medical necessity reviews and hearing outcomes
• Regularly review relevant topics via peer reviewed articles and evidence-based sources to identify changes in medical practice, treatments, and medications
• Work with medical, nursing, and administrative staff to identify matters needing shared attention
• May primarily work remotely but must be available onsite to the client as contractually required

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

• M.D. or D.O., eligible for or with current non-restricted license to practice medicine by the Tennessee Board of Medical Examiners.
• Current board certification in a clinical specialty is required. Internal medicine, pediatrics, or family medicine preferred
• Working knowledge of quality assurance and utilization review is required.

Knowledge, Skills, Abilities

• Ability to work effectively with a diversity of personalities. Must be approachable, show respect for others, and a consensus builder.
• Adaptable with strong collaborative management style, a creative thinker with high energy and enthusiasm, and a team player who promotes the concepts of people working together.
• Excellent writing skills and proficient with MS Office Suite

Experience

• 5+ years of clinical practice.