Medicaid Claims Review Specialist

Acentra Health; Oregon (WI); On-site; USD 71,205,000 - 83,097,000; Full time

Benefits offered by this job

Health plans

Retirement savings

Educational assistance

Job summary

Acentra Health is seeking a Medical Claims Reviewer to join our growing team and oversee billing and documentation policies for Oregon Health Plan services. You will work with team members and clients to ensure accurate determinations and compliance with Medicaid requirements.

The role combines claims review expertise with operational analysis, policy interpretation, systems coordination, and program implementation responsibilities.

Qualifications

• Bachelor's Degree required.
• Current coding certification from AAPC or AHIMA (CPC, COC, CIC, or CPMA).
• 2+ years of experience in medical claims review, healthcare operations, Medicaid administration, compliance, medical coding and billing or related healthcare functions.

Responsibilities

• Review claims, medical records, billing, and supporting documentation prior to payment to make accurate coverage and payment determinations.
• Audit claims and records for compliance with CPT guidelines, Medicaid requirements, Oregon Health Plan policies, federal and state regulations, and applicable program rules.
• Identify and investigate billing irregularities, errors, inconsistencies, services not provided, misrepresentations, inappropriate coding, potential fraud, and documentation concerns.
• Investigate and resolve denied claims, billing appeals, exception requests, provider disputes, reimbursement issues, and coverage inquiries.
• Research and respond to inquiries regarding compliance, coding, denials, billable services, coverage, reimbursement, documentation, and program requirements.
• Independently manage inpatient and outpatient claims while ensuring timely and appropriate reimbursement.
• Support the resolution of provider issues and serve as a resource to internal staff, providers, contractors, and other stakeholders.
• Interpret federal regulations, administrative rules, statutes, program guidance, and established policies as they apply to claims and operational situations.

Skills

Analytical skills

Attention to detail

Strong communication

Education

Bachelor's Degree

Coding certification (AAPC/AHIMA CPC/COC/CIC/CPMA)

Tools

Word

Excel

Visio

SharePoint

Webex

Skype

Job description

Acentra Health is seeking a Medical Claims Reviewer to join our growing team and oversee billing and documentation policies for Oregon Health Plan services. You will work with team members and clients to ensure accurate determinations and compliance with Medicaid requirements.

The role combines claims review expertise with operational analysis, policy interpretation, systems coordination, and program implementation responsibilities.