Physician Medical Reviewer (PRN) Remote within California

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 Physician Medical Reviewer-PRN to join our growing team.

Job Summary:

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 review clinical documentation, assess medical necessity, ensure compliance with established guidelines, and provide expert testimony during appeals hearings. This position offers an opportunity to apply your clinical expertise to support fair and evidence-based healthcare determinations.

Job Responsibilities:

• Prepare independent reviews of medical services appeals
• Review records, prepare and submit all reviews in keeping with the Acentra Health contractual due dates. These may include appeals by members and other key stakeholders.
• Critically evaluate the application of guidelines and protocols by managed care organizations, dental benefits manager, and pharmacy benefits manager to the individual enrollee's appeal. Take into consideration Rules of Medical Necessity, standards of care, evidence-based medicine, and hierarchy of evidence.
• 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 and consult with the assigned attorney prior to the hearing as needed
• Participate in quality assurance activities for medical necessity reviews and hearing outcomes
• Regularly review relevant topics via peer reviewed articles and evidence-based sources to identify changes in medical practice, treatments, and medications
• 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.

Required Qualifications, Knolwedge and Experience

• Must have Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) degree from an accredited institution required. Must possess a current, active, and unrestricted license to practice medicine in the State of California (or be eligible for California licensure) issued by a State Board of Medical Examiners.

• 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.

Preferred Qualifications

• Demonstrated ability to work effectively with individuals from diverse backgrounds and professional disciplines; approachable, respectful, and skilled at building consensus and fostering collaborative relationships.

• 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, clearly articulate complex medical concepts, and communicate effectively with internal and external stakeholders.

• Proficient in computer-based applications, including Microsoft Office Suite (Word, Excel, Outlook, and Teams), and other standard business 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. This position includes access to select Acentra Health benefits and programs, such as participation in the Acentra Health 401(k) Plan with company match, access to wellness and employee discount programs, and Employee Assistance Program (EAP) resources.

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!

~ The Acentra Health Talent Acquisition Team

Visit us at http://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 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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