Medicare Regulatory & Coding Expert — UM/PA Specialist

Acentra Health; United States; On-site; USD 40,000 - 50,000; Full time

Job summary

Acentra Health is seeking a Medicare Regulatory and Coding Expert Associate to join our team. You will apply CMS guidelines to maintain the Action Code Database (ACD) and ensure medical necessity decisions align with CMS, URAC, ERISA/DOL, and ACA guidelines.

You will collaborate with clients, their claims administrators, and internal teams to support prior authorizations and utilization management. The role requires RN licensure, medical coding certification, and strong Excel skills to manage

Qualifications

• Active, unrestricted RN with a Compact State License.
• Certified Medical Coder.
• 2+ years of clinical experience after graduation.
• 1+ year of Utilization Management (UM) and/or Prior Authorization experience.
• Experience with Part B Medicare.
• Advanced level skill with Microsoft Excel.
• Knowledge of CMS regulatory requirements and compliance.
• Familiarity with medical records organization and terminology.
• Proficient in Microsoft Office and internet navigation.
• Strong clinical assessment and critical thinking skills.
• Excellent verbal and written communication skills.
• Experience hosting and leading meetings.

Responsibilities

• Interpret CMS medical necessity and prior authorization guidelines.
• Maintain knowledge of CMS regulations, guidance documents, and transmittals.
• Maintain internal ACD spreadsheet and ACD database in Microsoft Access.
• Schedule and host ACD meetings with the client.
• Review CPT code reports and discuss with Manager.
• Maintain codes in the ACD and update with client collaboration.
• Assess patient records against criteria for medical necessity.
• Approve medically necessary requests; reference denials clearly in notes.
• Maintain HIPAA-compliant confidentiality of records.
• Communicate professionally per Acentra Health policies.
• Cross-train to perform duties of other roles as needed.
• Adhere to all corporate policies, including HIPAA.

Skills

RN license

Medical coding

CMS regulations

Excel advanced

Communication skills

Teamwork

Critical thinking

Education

Nursing degree

Tools

Microsoft Excel

Microsoft Office

MS Access (Preferred)

Job description

Acentra Health is seeking a Medicare Regulatory and Coding Expert Associate to join our team. You will apply CMS guidelines to maintain the Action Code Database (ACD) and ensure medical necessity decisions align with CMS, URAC, ERISA/DOL, and ACA guidelines.

You will collaborate with clients, their claims administrators, and internal teams to support prior authorizations and utilization management. The role requires RN licensure, medical coding certification, and strong Excel skills to manage