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. 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. 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.
Physician Medical Reviewer
Location
United States
Posted
9 days ago
Salary
$89 - $120 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
Role Description
Acentra Health is looking for a Physician Medical Reviewer-PRN to join our growing team.
Acentra Health is seeking a Physician Medical Claims Reviewer to support independent medical service appeal reviews for priority populations with complex healthcare needs. In this role, you will:
- Prepare independent reviews of medical services appeals.
- Review records, prepare and submit all reviews in keeping with the Acentra Health contractual due dates.
- Critically evaluate the application of guidelines and protocols by managed care organizations, dental benefits manager, and pharmacy benefits manager.
- 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.
- Participate in quality assurance activities for medical necessity reviews and hearing outcomes.
- Regularly review relevant topics via peer-reviewed articles and evidence-based sources.
- 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.
- Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.
The list of responsibilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.
Qualifications
- Must have Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) degree from an accredited institution.
- Must possess a current, active, and unrestricted license to practice medicine in the State of California (or be eligible for California licensure).
- Demonstrated work experience in Utilization Review within Behavioral Health Services.
- Strong working knowledge of quality assurance principles and utilization review processes within a healthcare or managed care environment.
- Minimum of 5+ years of professional clinical practice experience as a licensed physician.
- Experience working with Medicaid and/or Medi-Cal programs, including knowledge of applicable regulatory guidelines and medical necessity criteria.
- Previous experience in managed care, utilization management, or utilization review is required.
Requirements
- Demonstrated ability to work effectively with individuals from diverse backgrounds and professional disciplines.
- Adaptable professional with a collaborative leadership style, strong problem-solving abilities, and a proactive mindset.
- Detail-oriented with strong organizational skills, and the ability to prioritize tasks and manage multiple responsibilities while meeting established deadlines.
- Excellent written communication skills, with the ability to review and assess clinical determinations within established turnaround times.
- Proficient in computer-based applications, including Microsoft Office Suite (Word, Excel, Outlook, and Teams), and other standard business and collaboration tools.
Benefits
- Access to select Acentra Health benefits and programs.
- Participation in the Acentra Health 401(k) Plan with company match.
- Access to wellness and employee discount programs.
- Employee Assistance Program (EAP) resources.
Compensation
The compensation for this role is $88.70 hour - $120.00 hour. 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.
Job Requirements
- Must have Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) degree from an accredited institution.
- Must possess a current, active, and unrestricted license to practice medicine in the State of California (or be eligible for California licensure).
- Demonstrated work experience in Utilization Review within Behavioral Health Services.
- Strong working knowledge of quality assurance principles and utilization review processes within a healthcare or managed care environment.
- Minimum of 5+ years of professional clinical practice experience as a licensed physician.
- Experience working with Medicaid and/or Medi-Cal programs, including knowledge of applicable regulatory guidelines and medical necessity criteria.
- Previous experience in managed care, utilization management, or utilization review is required.
- Demonstrated ability to work effectively with individuals from diverse backgrounds and professional disciplines.
- Adaptable professional with a collaborative leadership style, strong problem-solving abilities, and a proactive mindset.
- Detail-oriented with strong organizational skills, and the ability to prioritize tasks and manage multiple responsibilities while meeting established deadlines.
- Excellent written communication skills, with the ability to review and assess clinical determinations within established turnaround times.
- Proficient in computer-based applications, including Microsoft Office Suite (Word, Excel, Outlook, and Teams), and other standard business and collaboration tools.
Benefits
- Access to select Acentra Health benefits and programs.
- Participation in the Acentra Health 401(k) Plan with company match.
- Access to wellness and employee discount programs.
- Employee Assistance Program (EAP) resources.
- Compensation
- The compensation for this role is $88.70 hour - $120.00 hour. 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.
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