Medical Claims Reviewer

Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes - making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra Health is looking for a Medical Claims Reviewer to join our growing team.

Job Summary:

The purpose of the Medical Claims Reviewer position is to work with team members and clients with respect to billing and documentation policies, procedures, regulations, and requests for clarification for inconsistent, debatable, or non-specific documentation. This role is a member of the Medical Claims Review team and reports directly to the Medical Claims Review Manager or Operations Manager.

**This is a remote position based within the State of Oregon or neighboring region within 45 minutes of the border.

Responsibilities:

• Function as an individual contributor and work under direct supervision
• Audit charts and adjudicate claims while ensuring all regulations are met in a timely manner
• Review claims prior to payment, resulting in initial determinations
• Audit records to identify irregularities or fraud by providers
• Ensure that billing is conducted in accordance with Current Procedural Terminology (CPT) guidelines.
• Review billing of services that were not provided, misrepresentations of services provided, and compliance with policies and procedures
• Ensure optimal reimbursement while adhering to federal and state regulations and Medicaid policies.
• Work with Provider Support on resolution of provider issues
• Review, research, investigate, and reply to inquiries concerning compliance, inappropriate coding, denials, and billable services
• Demonstrate basic knowledge of operations methodologies, best practices, and procedures; and learn to apply them to projects to ensure that operations objectives are achieved
• Adhere to company CMMI standards and processes
• Demonstrate an unwavering commitment to customer service and operational excellence
• Provide customer support as necessary
• Keep abreast of new statutory regulations and medical terminology
• Request and give both negative and positive feedback
• Demonstrate technical knowledge of statutory regulations and medical terminology
• Demonstrate basic knowledge of auditing concepts and principles
• Demonstrate basic knowledge of medical coding systems, procedures, and documentation
• Independently and effectively manage inpatient and outpatient claims
• Analyze and resolve issues
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules

Required Qualifications

• Bachelor's degree in a relevant field (e.g., Healthcare Administration, Medical Billing and Coding), or at least four years of technical-level experience in a related role that demonstrates equivalent knowledge and skills

Preferred Qualifications

• Certified Professional Medical Auditor (CPMA)
• Certified as an Assistive Technology Professional (ATP)
• Certified Professional Coder (CPC)
• Current coding certification from AAPC, AHIMA, or RESNA
• Experience in medical coding systems, billing procedures, and documentation requirements
• Technical knowledge of statutory regulations and medical terminology
• Knowledge of auditing concepts and principles
• Understanding of SharePoint applications, Webex, Skype, etc
• Knowledge of Microsoft Word, Excel, and Visio, with a working knowledge of the rest of the Microsoft Office suite of applications
• Domain knowledge of Medicare, Medicaid, or healthcare verticals
• Demonstrates flexibility in working under demands and needs of the project
• Ability to work within multiple groups of employees, willingly share time, knowledge, and information with others
• Ability to understand business needs, analyze processes, and develop alternative solutions
• Excellent written and verbal communication skills, including the ability to convey technical details to providers, clients, and staff
• Ability to interact with persons at all levels in the business environment
• Strong sense of team and Flexibility to complete work outside of primary scope of work, when needed

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 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

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.

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

Visit us at Acentra.com/careers/

EEO 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, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

Compensation

The pay range for this position is listed below.

"Based on our compensation philosophy, 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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