Medical Claims Reviewer

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 Medical Claims Reviewer to join our growing team.

Job Summary:

The purpose of the Medical Claims Reviewer position is to work with team members and clients with respect to billing and documentation policies, procedures, regulations, and requests for clarification for inconsistent, debatable, or non-specific documentation. This role is a member of the Medical Claims Review team and reports directly to the Medical Claims Review Manager or Operations Manager.

This position supports the administration and oversight of Oregon Health Plan Professional Services programs, including DMEPOS, Therapies, Vision, and Dental services. The role combines medical claims review expertise with operational analysis, policy interpretation, systems coordination, and program implementation responsibilities. The Medical Claims Reviewer reviews claims, billing appeals, provider inquiries, and policy issues while ensuring compliance with Medicaid requirements and program regulations.

• Review claims, medical records, billing, and supporting documentation prior to payment to make accurate coverage and payment determinations.
• Audit claims and records for compliance with CPT guidelines, Medicaid requirements, Oregon Health Plan policies, federal and state regulations, and applicable program rules.
• Identify and investigate billing irregularities, errors, inconsistencies, services not provided, misrepresentations, inappropriate coding, potential fraud, and documentation concerns.
• Investigate and resolve denied claims, billing appeals, exception requests, provider disputes, reimbursement issues, and coverage inquiries.
• Research and respond to inquiries regarding compliance, coding, denials, billable services, coverage, reimbursement, documentation, and program requirements.
• Independently manage inpatient and outpatient claims while ensuring timely and appropriate reimbursement.
• Support the resolution of provider issues and serve as a resource to internal staff, providers, contractors, and other stakeholders.
• Interpret federal regulations, administrative rules, statutes, program guidance, and established policies as they apply to claims and operational situations.
• Receive, track, research, and resolve program related questions and requests for technical assistance.
• Prepare written explanations, interpretations, reports, issue summaries, recommendations, and operational analyses.
• Conduct analytical studies and operational research to evaluate program effectiveness, identify trends, and support decision making.
• Evaluate regulations, statutes, policies, and procedures and recommend improvements to address operational challenges.
• Monitor program performance, compliance, and customer service outcomes.
• Participate in task forces, work groups, advisory committees, public meetings, and special projects.
• Develop, maintain, and update provider guidance, billing instructions, policies, procedures, manuals, training materials, and operational documentation.
• Track action items and coordinate follow up activities with internal and external stakeholders.
• Collaborate with business systems and information technology staff to implement system enhancements and resolve system issues.
• Analyze business requirements and operational reporting needs and translate operational requirements into functional specifications for technical teams.
• Create test scenarios, participate in user acceptance testing, and recommend corrective actions.
• Develop user procedures, system documentation, and training materials related to system and process changes.
• Monitor legislative activity and evaluate proposed legislation and regulatory changes for operational impacts.
• Assist with policy development, legislative analysis, administrative…