Medical Claims Reviewer

Acentra Health, LLC•UNAVAILABLE, Oregon

23h

About The Position

Acentra Health is seeking a Medical Claims Reviewer to support healthcare claims administration and oversight. The role combines claims review, compliance auditing, operational analysis, policy interpretation, systems coordination, stakeholder support, and program implementation. The reviewer evaluates claims, billing appeals, provider inquiries, reimbursement issues, and policy-related matters to ensure compliance with regulations, coding standards, reimbursement requirements, and organizational policies. The position also supports process improvements, business analysis, systems enhancements, policy and training documentation, and implementation of regulatory or organizational changes. It primarily involves desk work and extended computer use. The role must adhere to corporate policies, including HIPAA Privacy and Security Rules; other duties may be assigned.

Requirements

Bachelor's degree or equivalent combination of experience and education.
At least 2 years of experience in medical claims review, healthcare operations, compliance, medical coding and billing, healthcare program administration, or related healthcare functions.

Nice To Haves

Knowledge of healthcare regulations, medical terminology, coding systems, auditing concepts, billing procedures, and documentation requirements.
Understanding of healthcare claims processing systems and claims administration processes.
Knowledge of Medicare, Medicaid, or healthcare operations.
Strong analytical, problem-solving, process improvement, and communication skills.
Experience with standard business software and collaboration tools.
For non-clinical roles, six years of directly relevant professional experience may substitute for a Bachelor's degree; with an Associate's degree, three years of directly relevant professional experience may substitute.

Responsibilities

Review claims, medical records, billing information, and supporting documentation to determine coverage and reimbursement.
Audit claims and records for compliance with coding guidelines, reimbursement requirements, regulations, policies, and program rules.
Identify and investigate billing irregularities, errors, coding concerns, documentation deficiencies, and potential fraud or abuse.
Resolve denied claims, billing appeals, provider disputes, reimbursement issues, exception requests, and coverage inquiries.
Research and respond to questions concerning coding, compliance, reimbursement, coverage, billing, and documentation requirements.
Manage inpatient and outpatient claim reviews and ensure timely reimbursement determinations.
Serve as a resource to providers, internal staff, contractors, and other stakeholders.
Interpret regulations, statutes, administrative rules, guidance, and policies related to claims and operational issues.
Research and resolve program-related questions and provide technical assistance.
Prepare reports, analyses, recommendations, issue summaries, and written interpretations.
Conduct operational studies and analyses to identify trends, evaluate effectiveness, and support decision-making.
Evaluate policies, regulations, and procedures and recommend operational improvements.
Monitor program performance, compliance, and service outcomes.
Participate in workgroups, committees, meetings, and special projects.
Develop and maintain policies, procedures, manuals, training materials, guidance documents, and operational documentation.
Coordinate activities and follow-up actions with internal and external stakeholders.
Collaborate with business systems and information technology teams to implement system improvements and resolve issues.
Analyze business requirements and translate operational needs into functional specifications.
Participate in testing activities and recommend corrective actions.
Develop user procedures and documentation related to system and process changes.
Evaluate legislative and regulatory changes for potential operational impacts.
Assist with policy development, regulatory implementation, and operational change management.
Apply knowledge of medical coding systems, auditing concepts, medical terminology, and healthcare operations.
Read, understand, and adhere to corporate policies, including HIPAA Privacy and Security Rules.
Perform other duties as assigned.