Medicare Regulatory & Coding Expert Associate

Acentra Health; McLean (VA); On-site; USD 40,000 - 51,000; Full time

Job summary

Acentra Health is seeking a Medicare Regulatory and Coding Expert Associate to join our team in a regulatory coding capacity. You will manage an internal ACD database, monitor CMS transmittals, and collaborate with clients and claims administrators to ensure compliance and accuracy.

The role requires applying medical necessity criteria, maintaining QA standards, and ensuring HIPAA compliance while supporting utilization management initiatives and producing timely, accurate guidance for clinical

Qualifications

• Active, unrestricted RN license with a Compact State.
• Graduation from an accredited Nursing Degree Program.
• 2+ years of clinical experience after graduation.
• 1+ year of Utilization Management or Prior Authorization experience.

Responsibilities

• Review CMS medical necessity and prior authorization guidelines.
• Maintain CMS regulations updates and internal ACD database in Access.
• Interpret patient records to determine medical necessity and appropriateness of care.
• Approve medically necessary requests and document rationale for denials.

Skills

Clinical assessment

Critical thinking

Communication

Team collaboration

Meeting facilitation

Education

RN license (Compact State)

Nursing degree

Tools

Microsoft Excel

Microsoft Access

Microsoft Office

Job description

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.

Job Summary and Responsibilities

Acentra Health is looking for a Medicare Regulatory and Coding Expert Associate to join our growing team.

Job Summary:

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 the medical appropriateness of requested services. Maintaining production goals, QA standards, and compliance with CMS, URAC, ERISA/DOL, ACA requirements/guidelines, and timelines is a critical part of the position.

Responsibilities:

• 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 the 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 the reason for the denial is described in sufficient detail in correspondence.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Acentra Health 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.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

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

Qualifications

Required Qualifications

• Active, unrestricted a Registered Nurse (RN) with a Compact State License.
• Certified Medical Coder
• Graduation from an accredited Nursing Degree Program.
• 2+ years of clinical experience working independently after graduating from college.
• 1+ year of Utilization Management (UM) and/or Prior Authorization or related experience.
• Experience with Part B Medicare.
• Advanced level skill with Microsoft Excel
• Knowledge of CMS regulatory requirements, compliance, and quality requirements.
• Knowledge of the organization of medical records, medical terminology, and disease process.
• Must be proficient in Microsoft Office and internet/web navigation.
• Strong clinical assessment and critical thinking skills.
• Excellent verbal and written communication skills.
• Experience hosting and leading meetings with excellent note-taking skills and is able to follow-up as needed.
• Ability to work in a team environment or independently but seek guidance where necessary.
• Flexibility and strong organizational skills.

Preferred Qualifications

• Medicare Advantage regulations/requirements experience
• Knowledge of current URAC standards.
• Microsoft Access experience.

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 Health

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.

Experience in Lieu of Degree

For non-clinical roles, or when not required by the contract specifically, the Company acknowledges that practical, hands-on experience can provide skills and competencies equivalent to formal education. As such, in cases where a Bachelor's degree may be required, the Company will accept a minimum of six (6) years of directly relevant professional experience in lieu of a degree. In instances where the candidate has an Associate's degree, the Company will accept a minimum of three (3) years of directly relevant professional experience in lieu of the Bachelor's degree.

Compensation

The pay 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."

Pay Range

USD $29.25 - USD $36.56 /Hr.