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 work groups, 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…