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Job Summary: The primary responsibilities of a Psychiatrist (PRN) / Claims Reviewer include conducting independent medical service appeal reviews, providing expert testimony, and ensuring compliance with guidelines. The position is remote and requires a M.D. or D.O. license to practice in the State of Maine. Job Responsibilities: Prepare independent reviews of behavioral health 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.
Work setup: Remote