Physician Medical Reviewer-PRN

Acentra Health; United States; Hybride; USD 122 193 - 192 864; Plein temps

Avantages offerts par ce poste

Retirement savings

Corporate wellness

Educational assistance

Corporate discounts

Résumé du poste

Acentra Health is seeking a Physician Medical Claims Reviewer to conduct independent medical service appeal reviews. The role includes critical evaluation of guidelines and protocols related to behavioral health services.

Candidates must possess an M.D. or D.O. with a current non-restricted license in Maine and have experience with Utilization Review. The position offers the opportunity for remote work while ensuring compliance with contractual requirements.

Qualifications

• M.D. or D.O. with a current non-restricted medical license from Maine.
• Utilization Review experience in Behavioral Health Services is required.
• Knowledge of quality assurance and utilization review processes is needed.

Responsabilités

• Prepare independent reviews of behavioral health services appeals.
• Review records and submit reviews keeping to contractual due dates.
• Critically evaluate guidelines and protocols in appeals.

Connaissances

Utilization Review experience in Behavioral Health Services

Quality assurance knowledge

Excellent writing skills

Proficient with MS Office Suite

Formation

M.D. or D.O. with current non-restricted medical license

3+ years of clinical practice

Experience with Medicaid

Description du poste

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

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.

EEO Statement

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.

Compensation

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 $88.70 - $140.00 /Hr.

Visit us at https://careers.acentra.com/jobs