Medicare Regulatory & Coding Expert — UM/ACD Specialist

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 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