Physician Medical Reviewer M.D. or D.O. - Part-time (Remote U.S.)

Acentra Health, LLC•UNAVAILABLE, UNAVAILABLE

1d•Remote

About The Position

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. Acentra is looking for a Part-time Physician Medical Reviewer (M.D. or D.O.) (Remote U.S. - Preferred within Tennessee) to join our growing team. The primary responsibilities of a Physician Medical Reviewer (M.D. or D.O.) include conducting independent medical service appeal reviews for TennCare and providing expert testimony.

Requirements

M.D. or D.O., with a current non-restricted license to practice medicine in the United States.
Current board certification.
5+ years of clinical practice (post-residency).
Excellent writing skills and proficient with MS Office Suite.
Work Schedule: Day Shift business hours to accommodate the Central Time Zone.
Travel to Tennessee: Minimal travel to the state of Tennessee with a preferred residence within a six-hour commute to Nashville.

Nice To Haves

Current board certification in Internal Medicine, Family Medicine, Primary Care or Disease Process, or Emergency Medicine.
Working knowledge of Quality Assurance (QA) and Utilization Review (UR).
Experience with Medicaid/Medicare.
Prior Managed Care/Utilization Review (UR) work experience.
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.

Responsibilities

Prepare independent reviews of medical services appeals.
Review records, prepare and submit all reviews in keeping with the TennCare/Acentra Health contractual due dates. These may include appeals by TennCare members, CoverKids members, Department of Intellectual & Developmental Disabilities clients, and Department of Commerce & Insurance appeals from TennCare providers.
Critically evaluate the application of guidelines and protocols by the TennCare managed care organizations, dental benefits manager, and pharmacy benefits manager to the individual enrollee’s appeal. Take into consideration TennCare 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 TennCare 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 in Nashville, Tennessee as contractually required.
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.
The above 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.