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?
• Are you motivated, energetic, and excited to become part of the Acentra Health team?
• Do you value care management and quality improvement?

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

• Maintain internal ACD spreadsheet and ACD database within Microsoft Access
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Kepro policies, procedures, and guidelines
• 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
• 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.
• Maintain current knowledge of CMS regulations, guidance documents, and transmittals
• Actively cross-trains to perform duties of other roles within this contract to provide a flexible workforce to meet client/consumer needs.
• 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.
• Schedule and host ACD meetings internally and with the client
• Review and accurately interpret CMS medical necessity and prior authorization guidelines

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

• Excellent verbal and written communication skills required.
• Flexibility and strong organizational skills needed.
• Knowledge of CMS medical necessity guidelines and benefit coverage criteria strongly preferred.
• Medical record abstraction skills required.
• Knowledge of the organization of medical records, medical terminology, and disease process required.
• Strong clinical assessment and critical thinking skills required.
• Must be proficient in Microsoft Office and internet/web navigation
• Ability to work in a team environment or independently but seek guidance where necessary required.
• Knowledge of current URAC standards preferred.
• Skilled in Microsoft Excel and Microsoft Access

Experience

• Experience with Medicare; required. Medicare Advantage experience (preferred)
• 1+ year of UM and/or Prior Authorization or related experience
• 2+ years of clinical experience.

Thank You!
We know your time is valuable and we thank you in advance for applying for this position. Due to the high volume of applicants we receive, 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
Mental And Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.
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, or status as a protected veteran.