Medicare Regulatory & Coding Expert - LPN/LVN or 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 - LPN/LVN or RN 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).

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.