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.