Physician Medical Reviewer M.D. or D.O. (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. The Physician Medical Reviewer (M.D. or D.O.) will conduct independent medical service appeal reviews for TennCare and provide expert testimony. This role involves critically evaluating the application of guidelines and protocols by managed care organizations, dental benefits manager, and pharmacy benefits manager to individual enrollee appeals, considering medical necessity rules, standards of care, and evidence-based medicine. The reviewer will also edit reviews by others, provide expert witness testimony, participate in quality assurance, and stay updated on medical practice changes. While primarily remote, availability for onsite client work in Nashville, Tennessee is required as contractually obligated. Adherence to corporate policies, including HIPAA, is mandatory.

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.

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.