Medical Policy Professional, Mid - Full-time (Remote U.S. within Alaska Time Zone Hours)

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 Policy Professional - Full-time, Mid (Remote U.S. within Alaska Time Zone Hours) to join our growing team.

Job Summary:

• The Medical Policy Professional is responsible for overseeing the accurate configuration, integration, and ongoing management of medical policy elements within the organization's healthcare solutions. This role serves as the primary point of contact for coordinating system configurations and ensuring alignment with service agreements (SAs) from thirdparty vendors. The Medical Policy Manager monitors all cap limits and medical review triggers and ensures appropriate routing for administrative or clinical review in partnership with the state's Utilization Management (UM) vendors.

Responsibilities:

• Serve as the main point of contact for proper configuration of medical policy solutions, ensuring seamless integration of service agreements (SAs) from external vendors.
• Oversee and manage system settings related to cap limits, medical review triggers, and other policy-driven configurations from external vendors.
• Monitor and initiate routing of cases requiring administrative review by the organization or referral for clinical medical review to the state's Utilization Management (UM) vendors.
• Collaborate with internal teams and external partners to ensure consistent policy application, compliance, and accuracy.
• Support development, maintenance, and updates of medical policy content in alignment with Medicaid, Medicare, and CMS guidelines.
• Troubleshoot configuration issues and escalate complex cases as needed to ensure policy integrity and operational efficiency.
• Provide expertise in coding, medical review criteria, and regulatory requirements, serving as a subject matter expert for the organization.
• Serves as backup to other administrative functions as assigned.
• Meets job standards for achieving contract deliverables.
• Assists with other job- and education-related duties as assigned.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

The above 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.

PLEASE NOTE:

* This role is contingent upon being awarded a contract. Start dates and final offers are contingent upon the contract award and final contract start dates. *

Required Qualifications/Experience:

• Must be available to work business hours as defined by contract within the Alaska Time Zone.
• Bachelor's degree (or higher level of education) in a related field (e.g., Health Information Management, Public Health, Healthcare Administration, Nursing, or related discipline).
• Certified Coding Specialist (CCS) credential from the American Health Information Management Association (AHIMA).
• 5+ years of experience in developing and managing medical policy or Utilization Management (UM) policy for state Medicaid agencies or Medicare.
• Strong working knowledge of Centers for Medicare & Medicaid Services (CMS) coding systems, including:
  • Procedure codes
  • Diagnostic codes
  • Dental/Current Dental Terminology (CDT)

Preferred Qualifications/Experience:

• Residency within Alaska, Pacific, OR Mountain Time Zone.
• Knowledge of Anatomy and Physiology.
• Ability to interpret medical terminology.
• Knowledge of Diagnosis Related Groups (DRG)/Ambulatory Payment Classification (APC) reimbursement.
• Proficiency with Medical Coding software.
• Effective written and verbal communication skills.
• Attention to detail.
• Efficient data entry skills.
• Proficiency in the Microsoft Office Suite (Word, Excel, Outlook).
• Ability to meet deadlines with a sense of urgency.

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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.

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 Acentra Health

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."