Physician Medical Reviewer-PRN

Acentra Health, LLC•UNAVAILABLE, UNAVAILABLE

2d•Hybrid

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. Job Summary: The primary responsibilities of a Physician Medical Claims Reviewer include conducting independent medical service appeal reviews, providing expert testimony, and ensuring compliance with guidelines. The 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.

Requirements

M.D. or D.O., with current non-restricted license to practice medicine by the Board of Medical Examiners in the State of Maine.
Must have Utilization Review experience in Behavioral Health Services.
Working knowledge of quality assurance and utilization review is required.
3+ years of clinical practice.
Experience with Medicaid

Nice To Haves

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.
Excellent writing skills and proficient with MS Office Suite

Responsibilities

Prepare independent reviews of behavioral health services appeals
Review records, prepare and submit all reviews in keeping with the Acentra Health contractual due dates. These may include appeals by members and other key stakeholders.
Critically evaluate the application of guidelines and protocols by managed care organizations, dental benefits manager, and pharmacy benefits manager to the individual enrollee’s appeal. Take into consideration 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 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 as contractually required
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.