About the job
DescriptionFollowing a 2022 merger of CNSI and Kepro, Acentra Health combines clinical services, technology solutions, and data analytics to accelerate better health outcomes. This is a great time to join our team of passionate individuals working together to pursue the most effective solutions to today’s complex healthcare challenges. Our culture is fueled by passion and driven by purpose.Medicare Regulatory and Coding Expert/ACD (LPN/RN) – Remote U.S.
- Are you an experienced Medicare Regulatory and Coding Expert looking for a new challenge?
- Are you looking to join a team that ensures a collaborative and inviting culture where everyone can thrive?
If so, you might be our next new team member!
- The selected candidate may work remotely from anywhere in the United States. **
- The required work hours for the selected candidate are Monday-Friday 8:00 AM – 5:00 PM Eastern (excluding Company Holidays). **
Who we need: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, and 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 is a critical part of the position.Why us?We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.Singularly Focused. Mission Driven. Accelerating Better Outcomes is our Mantra! We are mission-driven to innovate health solutions that deliver maximum value and impact.We do this through our people.You will have meaningful work that genuinely improves people’s lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.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 comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.What you’ll do:
- Review and accurately interpret CMS medical necessity and prior authorization guidelines.
- Maintain current knowledge of CMS regulations, guidance documents, and transmittals.
- Maintain internal ACD spreadsheet and ACD database within Microsoft Access.
- Schedule and host ACD meetings internally and with the client.
- Review monthly CPT code report and make suggestions based on the data, review with the Manager prior to meetings.
- Perform ongoing assessment and maintenance of codes within the ACD and update as appropriate in collaboration with the manager and client.
- Review and interpret patient records and compare against criteria to determine medical necessity and appropriateness of care; determine if the medical record documentation supports the need for services.
- Approve medically necessary requests; refer those not meeting criteria to the physician reviewer; process physician decisions ensuring the reason for the denial is described in sufficient detail in correspondence.
- Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
- Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Acentra Health policies, procedures, and guidelines
- Actively cross-trains to perform duties of other roles within this contract to provide a flexible workforce to meet client/consumer needs.
The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.What you’ll need:Required Qualifications
- Active, unrestricted Licensed Practical Nurse (LPN) or a Registered Nurse (RN) with a Compact State License.
- Graduation from an accredited Nursing Degree Program.
- Certified Medical Coder.
Knowledge, Skills, Abilities (Required)
- Knowledge of CMS regulatory requirements, compliance, and quality requirements.
- Knowledge of the organization of medical records, medical terminology, and disease process.
- Must be proficient in Microsoft Office and internet/web navigation.
- Skilled in Microsoft Excel.
- Strong clinical assessment and critical thinking skills.
- Excellent verbal and written communication skills.
- Ability to work in a team environment or independently but seek guidance where necessary.
- Flexibility and strong organizational skills.
Knowledge, Skills, Abilities (Preferred)
- Knowledge of current URAC standards.
- Microsoft Access experience.
- 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 Medicare.
- Medicare Advantage regulations/requirements experience.
Thank You!We know your time is valuable, and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may be of interest. Best of luck in your search!~ The Acentra Health Talent Acquisition TeamEOE AA M/F/Vet/DisabilityAcentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by applicable Federal, State, or Local law.