Medicare Regulatory and Coding Expert - LPN/LVN/RN (Remote U.S.)

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 Health is looking for a Medicare Regulatory and Coding Expert to join our growing team.

Job Summary:

This position utilizes expertise in medical coding and knowledge of Medicare Coverage Guidelines to maintain an internal, client-specific prior authorization guidelines reference tool referred to as the Action Code Database (ACD).

Maintaining the database requires monitoring CMS transmittals and regulatory updates, reviewing internal prior authorization trends, and collaborating with the internal team, the client, and the client's claims administrator.

This position also serves as a member of the utilization management team and requires expertise in applying medical necessity criteria, critical thinking, and decision-making skills to determine the medical appropriateness of requested services. Maintaining production goals, QA standards, and compliance with CMS, URAC, ERISA/DOL, ACA requirements/guidelines, and timelines is a critical part of the position.

The required work hours for the selected candidate are Monday-Friday 8:00 AM - 5:00 PM Eastern (excluding Company Holidays).

Responsibilities:

• Review and accurately interpret CMS medical necessity and prior authorization guidelines.
• Maintain current knowledge of CMS regulations, guidance documents, and transmittals.
• Maintain internal Action Code Database (ACD) spreadsheet and ACD database within Microsoft Access.
• Schedule and host ACD meetings internally and with the client.
• Review monthly CPT code report and make suggestions based on the data, review with the Manager prior to meetings.
• Perform ongoing assessment and maintenance of codes within the ACD and update as appropriate in collaboration with the manager and client.
• Review and interpret patient records and compare against criteria to determine medical necessity and appropriateness of care; determine if the medical record documentation supports the need for services.
• Approve medically necessary requests; refer those not meeting criteria to the physician reviewer; process physician decisions ensuring the reason for the denial is described in sufficient detail in correspondence.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following Acentra Health policies, procedures, and guidelines.
• Actively cross-trains to perform duties of other roles within this contract to provide a flexible workforce to meet client/consumer needs.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

Required Qualifications/Experience:

• Current Licensure: Active and unrestricted LPN/LVN or RN with a Compact State License.
• Certification: 2+ years of experience as a Certified Medical Coder/Certified Professional Coder (CMC/CPC) or other relevant certifications.
• Education: Graduation from an accredited Nursing Degree Program.
• Clinical Experience: 2+ years of independent clinical experience post-graduation with a Nursing degree.
• Utilization Management: 1+ years of experience in Utilization Management (UM), Prior Authorization, or related fields.
• Medicare Knowledge: 1+ years of experience with Part B Medicare.
• Regulatory Expertise: 1+ years of knowledge with CMS regulatory requirements, compliance, and quality standards.
• Medical Records Knowledge: 1+ years of knowledge of medical records organization, medical terminology, and disease processes.
• Technical Proficiency: Proficient in Microsoft Office and web navigation.
• Clinical Skills: Strong clinical assessment and critical thinking abilities.
• Communication: Excellent verbal and written communication skills.
• Leadership: Experience in hosting and leading meetings, with strong notetaking and follow-up skills.
• Teamwork and Independence: Ability to work collaboratively in a team or independently, seeking guidance, as necessary.
• Organizational Skills: Flexible and robust organizational abilities.

Preferred Qualifications/Experience:

• Medicare Advantage: Experience with Medicare Advantage regulations/requirements.
• URAC Standards: Knowledge of current Utilization Review Accreditation Commission (URAC) standards.
• Technical Skills: Microsoft Access experience.

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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.

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

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EEO 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.

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 listed below.

"Based on our compensation philosophy, an applicant's position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level."