Job Description

Description CNSI and Kepro are now Acentra Health! 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 Physician Medical Claims Reviewer to join our growing team. Job Summary: The primary responsibilities of a Physician Medical Claims Reviewer include conducting independent medical service appeal reviews for TennCare, providing expert testimony, and ensuring compliance with guidelines. Job 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 as contractually required. Requirements Required Qualifications/Experience M.D. or D.O., eligible for or with current non-restricted license to practice medicine by the Tennessee Board of Medical Examiners. Current board certification in a clinical specialty is required. Internal medicine, pediatrics, or family medicine. 5+ years of clinical practice. Must be available to work day shift hours to accommodate CST time zone? Preferred Qualifications/Experience: Working knowledge of quality assurance and utilization review. Experience with Medicaid/Medicare. Prior managed care/utilization review 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. Excellent writing skills and proficient with MS Office Suite. Benefits Why us? We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes. We do this through our people. You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career. Benefits Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more. Compensation The pay range for this position is $184,500-$200,000 annually "Based on our compensation program, an applicant's position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level." Thank You! We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may be of interest. Best of luck in your search! ~ The Acentra Health Talent Acquisition Team Visit us at Acentra.com/careers/ EOE AA M/F/Vet/Disability Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

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