Medical Claims Reviewer

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.

At Acentra Health, we embrace emerging technologies, including artificial intelligence and advanced analytics that can be utilized to improve processes, enhance decision-making, and drive better health outcomes. We value professionals who are curious about new technologies and motivated to use innovative tools to increase efficiency, quality, and impact in their roles.

Acentra Health is looking for a Medical Claims Reviewer to join our growing team.

Job Summary:

This position supports healthcare claims administration and oversight activities through a combination of claims review, compliance auditing, operational analysis, policy interpretation, systems coordination, and program implementation responsibilities.

The role is responsible for reviewing claims, billing appeals, provider inquiries, reimbursement issues, and policy-related matters to ensure compliance with applicable regulations, coding standards, reimbursement requirements, and organizational policies. The position also supports operational improvements, business process analysis, systems enhancements, stakeholder support, policy development, training documentation, and implementation of regulatory or organizational changes.

Responsibilities:

• Review claims, medical records, billing information, and supporting documentation to determine coverage and reimbursement.
• Audit claims and records for compliance with coding guidelines, reimbursement requirements, regulations, policies, and program rules.
• Identify and investigate billing irregularities, errors, coding concerns, documentation deficiencies, and potential fraud or abuse.
• Resolve denied claims, billing appeals, provider disputes, reimbursement issues, exception requests, and coverage inquiries.
• Research and respond to questions related to coding, compliance, reimbursement, coverage, billing, and documentation requirements.
• Manage inpatient and outpatient claim reviews and ensure timely reimbursement determinations.
• Serve as a resource to providers, internal staff, contractors, and other stakeholders.
• Interpret regulations, statutes, administrative rules, guidance, and policies related to claims and operational issues.
• Research and resolve program-related questions and provide technical assistance.
• Prepare reports, analyses, recommendations, issue summaries, and written interpretations.
• Conduct operational studies and analyses to identify trends, evaluate effectiveness, and support decision-making.
• Evaluate policies, regulations, and procedures and recommend operational improvements.
• Monitor program performance, compliance, and service outcomes.
• Participate in workgroups, committees, meetings, and special projects.
• Develop and maintain policies, procedures, manuals, training materials, guidance documents, and operational documentation.
• Coordinate activities and follow-up actions with internal and external stakeholders.
• Collaborate with business systems and information technology teams to implement system improvements and resolve issues.
• Analyze business requirements and translate operational needs into functional specifications.
• Participate in testing activities and recommend corrective actions.
• Develop user procedures and documentation related to system and process changes.
• Evaluate legislative and regulatory changes for potential operational impacts.
• Assist with policy development, regulatory implementation, and operational change management.
• Apply knowledge of medical coding systems, auditing concepts, medical terminology, and healthcare operations.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.
• This position primarily involves working at a desk and using a computer for extended periods of time
• Other duties as assigned

The list of accountabilities 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.

Required Qualifications

• Bachelor's degree or equivalent combination of experience and education.
• 2+ experience in medical claims review, healthcare operations, compliance, medical coding and billing, healthcare program administration, or related healthcare functions.

Preferred Qualifications

• Knowledge of healthcare regulations, medical terminology, coding systems, auditing concepts, billing procedures, and documentation requirements.
• Understanding of healthcare claims processing systems and claims administration processes.
• Knowledge of Medicare, Medicaid, or healthcare operations.
• Strong analytical, problem-solving, process improvement, and communication skills.
• Experience with standard business software and collaboration tools.

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.

Experience in Lieu of Degree

For non-clinical roles, or when not required by the contract specifically, the Company acknowledges that practical, hands-on experience can provide skills and competencies equivalent to formal education. As such, in cases where a Bachelor's degree may be required, the Company will accept a minimum of six (6) years of directly relevant professional experience in lieu of a degree. In instances where the candidate has an Associate's degree, the Company will accept a minimum of three (3) years of directly relevant professional experience in lieu of the Bachelor's degree.

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!

We are committed to providing a secure and positive hiring experience. Depending on the role, interviews may be conducted virtually, in person, or through a combination of both. As part of our recruitment process, candidates may be asked to participate in identity verification measures to help ensure the integrity of the hiring process.

~ The Acentra Health Talent Acquisition Team

Visit us at https://careers.acentra.com/jobs

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, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

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.”