[Hiring] Medicare Regulatory & Coding Expert Associate @Acentra Health, LLC

Role Description

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

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
• 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

Responsibilities include:

• Reviewing and accurately interpreting CMS medical necessity and prior authorization guidelines
• Maintaining current knowledge of CMS regulations, guidance documents, and transmittals
• Maintaining internal ACD spreadsheet and ACD database within Microsoft Access
• Scheduling and hosting ACD meetings internally and with the client
• Reviewing monthly CPT code report and making suggestions based on the data
• Performing ongoing assessment and maintenance of codes within the ACD
• Reviewing and interpreting patient records to determine medical necessity and appropriateness of care
• Approving medically necessary requests and processing physician decisions
• Maintaining medical records confidentiality at all times
• Utilizing proper telephone etiquette and following Acentra Health policies
• Actively cross-training to perform duties of other roles within this contract
• Reading, understanding, and adhering to all corporate policies including HIPAA

Qualifications

• Active, unrestricted 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
• 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
• Ability to work in a team environment or independently
• Flexibility and strong organizational skills

Requirements

• Medicare Advantage regulations/requirements experience (preferred)
• Knowledge of current URAC standards (preferred)
• Microsoft Access experience (preferred)

Benefits

• Comprehensive health plans
• Paid time off
• Retirement savings
• Corporate wellness
• Educational assistance
• Corporate discounts
• Additional protection, security, and support for both your career and life away from work