Physician Medical Reviewer-PRN

Acentra Health; McLean (VA); Hybrid; USD 122,193 - 192,864; Full time

Benefits offered by this job

Retirement savings

Corporate wellness

Educational assistance

Corporate discounts

Job summary

Acentra Health in McLean, Virginia is seeking a Physician Medical Reviewer to join their team. The role involves conducting independent reviews of behavioral health services and providing expert testimony as needed. The ideal candidate will have an M.D. or D.O. degree, with at least 3 years of clinical practice and experience in Utilization Review.

Acentra Health offers competitive pay rates ranging from $88.70 to $140.00 per hour, alongside a comprehensive benefits package designed to support both work and personal life.

Qualifications

• Must have Utilization Review experience in Behavioral Health Services.
• 3+ years of clinical practice required.
• Must hold a current non-restricted license to practice medicine.

Responsibilities

• Conduct independent reviews of behavioral health services appeals.
• Evaluate guidelines and protocols applied to individual enrollee's appeals.
• Provide expert medical witness testimony in appeals hearings.

Skills

Utilization Review experience

Clinical practice

Excellent writing skills

Proficient with MS Office Suite

Education

M.D. or D.O.

Job description

Company Overview

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 Physician Medical Reviewer to join our growing team.

Job Summary:The primary responsibilities of a Physician Medical Claims Reviewer include conducting independent medical service appeal reviews, providing expert testimony, and ensuring compliance with guidelines.

Job Responsibilities:

• Prepare independent reviews of behavioral health services appeals
• Review records, prepare and submit all reviews in keeping with the Acentra Health contractual due dates. These may include appeals by members and other key stakeholders.
• Critically evaluate the application of guidelines and protocols by managed care organizations, dental benefits manager, and pharmacy benefits manager to the individual enrollee's appeal. Take into consideration Rules of Medical Necessity, standards of care, evidence-based medicine, and hierarchy of evidence.
• Review relevant peer reviewed research and evidence-based sources as needed
• Edit Medical Necessity Reviews authored by other reviewers
• Provide expert medical witness testimony for the State in appeals hearings and consult with the assigned attorney prior to the hearing as needed
• Participate in quality assurance activities for medical necessity reviews and hearing outcomes
• Regularly review relevant topics via peer reviewed articles and evidence-based sources to identify changes in medical practice, treatments, and medications
• Work with medical, nursing, and administrative staff to identify matters needing shared attention
• May primarily work remotely but must be available onsite to the client as contractually required
• 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 education- and experience-related duties that management may deem necessary from time to time.

Qualifications

Required Qualifications

• M.D. or D.O., with current non-restricted license to practice medicine by the Board of Medical Examiners in the State of Maine.
• Must have Utilization Review experience in Behavioral Health Services.
• Working knowledge of quality assurance and utilization review is required.
• 3+ years of clinical practice.
• Experience with Medicaid

Preferred Qualifications

• Ability to work effectively with a diversity of personalities. Must be approachable, show respect for others, and a consensus builder.
• Adaptable with strong collaborative management style, a creative thinker with high energy and enthusiasm, and a team player who promotes the concepts of people working together.
• Excellent writing skills and proficient with MS Office Suite

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 retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

Pay Range

USD $88.70 - USD $140.00 /Hr.

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.