Medical Claims Reviewer

Acentra Health, LLC•UNAVAILABLE, Oregon

About The Position

Acentra Health is looking for a Medical Claims Reviewer to join our growing team. The purpose of the Medical Claims Reviewer position is to work with team members and clients with respect to billing and documentation policies, procedures, regulations, and requests for clarification for inconsistent, debatable, or non-specific documentation. This role is a member of the Medical Claims Review team and reports directly to the Medical Claims Review Manager or Operations Manager. This position supports the administration and oversight of Oregon Health Plan Professional Services programs, including DMEPOS, Therapies, Vision, and Dental services. The role combines medical claims review expertise with operational analysis, policy interpretation, systems coordination, and program implementation responsibilities. The Medical Claims Reviewer reviews claims, billing appeals, provider inquiries, and policy issues while ensuring compliance with Medicaid requirements and program regulations.

Requirements

Bachelor's Degree.
Current coding certification from AAPC or AHIMA as a CPC, COC, CIC, or CPMA.
2+ years of experience in medical claims review, healthcare operations, Medicaid administration, compliance, medical coding and billing or related healthcare functions.

Nice To Haves

Knowledge of statutory regulations, medical terminology, medical coding systems, auditing concepts, billing procedures, and documentation requirements.
Understanding of the State MMIS system, Medicaid operations, and the claims release process.
Domain knowledge of Medicare, Medicaid, or healthcare operations.
Experience using Microsoft Office applications, including Word, Excel, and Visio, as well as SharePoint, Webex, Skype, or similar collaboration tools.
Strong analytical, critical thinking, problem-solving, and process improvement skills, including the ability to understand business needs, analyze processes, identify solutions, and make recommendations.
Strong attention to detail and the ability to manage multiple assignments in accordance with project demands.
Initiative, enthusiasm, creativity, flexibility, and resourcefulness when handling assignments.
Ability to work effectively with multiple groups and willingly share time, knowledge, and information with others.
Excellent written and verbal communication skills, including the ability to explain technical information to providers, clients, staff, and stakeholders at all levels.

Responsibilities

Review claims, medical records, billing, and supporting documentation prior to payment to make accurate coverage and payment determinations.
Audit claims and records for compliance with CPT guidelines, Medicaid requirements, Oregon Health Plan policies, federal and state regulations, and applicable program rules.
Identify and investigate billing irregularities, errors, inconsistencies, services not provided, misrepresentations, inappropriate coding, potential fraud, and documentation concerns.
Investigate and resolve denied claims, billing appeals, exception requests, provider disputes, reimbursement issues, and coverage inquiries.
Research and respond to inquiries regarding compliance, coding, denials, billable services, coverage, reimbursement, documentation, and program requirements.
Independently manage inpatient and outpatient claims while ensuring timely and appropriate reimbursement.
Support the resolution of provider issues and serve as a resource to internal staff, providers, contractors, and other stakeholders.
Interpret federal regulations, administrative rules, statutes, program guidance, and established policies as they apply to claims and operational situations.
Receive, track, research, and resolve program related questions and requests for technical assistance.
Prepare written explanations, interpretations, reports, issue summaries, recommendations, and operational analyses.
Conduct analytical studies and operational research to evaluate program effectiveness, identify trends, and support decision making.
Evaluate regulations, statutes, policies, and procedures and recommend improvements to address operational challenges.
Monitor program performance, compliance, and customer service outcomes.
Participate in task forces, workgroups, advisory committees, public meetings, and special projects.
Develop, maintain, and update provider guidance, billing instructions, policies, procedures, manuals, training materials, and operational documentation.
Track action items and coordinate follow up activities with internal and external stakeholders.
Collaborate with business systems and information technology staff to implement system enhancements and resolve system issues.
Analyze business requirements and operational reporting needs and translate operational requirements into functional specifications for technical teams.
Create test scenarios, participate in user acceptance testing, and recommend corrective actions.
Develop user procedures, system documentation, and training materials related to system and process changes.
Monitor legislative activity and evaluate proposed legislation and regulatory changes for operational impacts.
Assist with policy development, legislative analysis, administrative rulemaking, and implementation of legislative and regulatory changes.
Demonstrate knowledge of medical coding systems, auditing concepts, medical terminology, operations methodologies, and applicable regulatory requirements.
Adhere to company CMMI standards and processes and all corporate policies, including policies related to HIPAA and its Privacy and Security Rules.