Clinical Appeals Professional; Remote Maine

Company Overview

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 Clinical Appeals Professional to join our growing team.

Job Summary

The Clinical Appeals Professional plays a key role in a collaborative, high‑performing team dedicated to ensuring fair, accurate, and compliant clinical decision‑making. This position is ideal for a state‑licensed clinician who is passionate about applying clinical expertise to support defensible outcomes, regulatory excellence in healthcare services.

The Clinical Appeals Professional is responsible for maintaining and updating case data within designated systems, reviewing required documentation, and conducting research to determine appropriate next steps in the appeals process. This role includes proactive outreach to healthcare providers to obtain necessary records, coordinating physician schedules, and representing Acentra Health in assigned DHHS appeals. You may also collaborate with providers during reconsideration discussions while supporting operational and administrative functions that drive an efficient, professional, and clinically sound appeals experience.

Job Responsibilities

• Clinical Review and Medical Necessity Determination;
  Review and interpret medical records to evaluate completeness, clinical appropriateness, and medical necessity related to coverage determinations, levels of care, and appeal outcomes.
• Apply evidence‑based clinical guidelines, state‑specific regulations, and contractual requirements while exercising sound professional clinical judgment.
• Identify gaps in documentation and determine additional clinical information needed to support accurate, defensible determinations.

Appeals Management & Hearings Representation

• Coordinate and manage appeal cases throughout the full review lifecycle, including initial review, reconsideration, and fair hearing processes.
• Prepare, present, and defend clinical determinations during hearings, including providing testimony and responding to clinical inquiries in alignment with licensure requirements.
• Represent the organization professionally in hearings and external proceedings as a trusted clinical subject‑matter expert.

Clinical Communication & Provider Engagement

• Conduct proactive outreach to healthcare providers and health plans to obtain medical records, clarify documentation, and support reconsideration discussions.
• Engage in peer‑to‑peer clinical dialogue regarding treatment plans, clinical indicators, discharge readiness, and appropriate levels of care to facilitate timely resolution.
• Maintain clear, professional communication with internal and external stakeholders to promote collaboration and workflow efficiency.

Coordination with Physician Reviewers

• Partner with physician reviewers to ensure accurate case assignment and timely completion of reviews.
• Support physician scheduling and case triage by prioritizing cases based on clinical complexity and stage of review.
• Ensure physician reviewers receive comprehensive, relevant clinical information to support informed and compliant decision‑making.

Risk, Quality, and Compliance

• Safeguard protected health information (PHI) by adhering to HIPAA Privacy and Security Rules and all regulatory standards.
• Apply strong clinical judgment to minimize risk of overturned determinations, regulatory non‑compliance, and organizational exposure.
• Maintain strict adherence to corporate policies, procedures, and compliance requirements.

Operational & Administrative Support

• Maintain…