Clinical Appeals Professional (Remote within Maine)

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 working knowledge of internal policies, procedures, and appeals workflows to support operational excellence.

• Accurately track and document appeals activities to ensure timely processing, reporting, and audit readiness.

• Coordinate case reassignment and follow-up actions upon completion of reviews or clinical discussions.

• Provide daily operational support for appeals functions and serve as backup for administrative and clinical tasks as needed.

• Read, understand, and comply with all corporate policies, including those related to HIPAA Privacy and Security.

• The list of accountabilities 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, Knowledge, and Experience

• Active, unrestricted RN, Social Worker, or other applicable clinical license in good standing within the required state and/or Compact State, as outlined by contractual requirements.

• Bachelor's degree from an accredited college or university in Nursing, Social Work, Social Services, or a closely related field.

• Proven experience in utilization management, clinical appeals, case management, and/or care coordination within payer and/or provider environments.

• Demonstrated ability to professionally present, articulate, and defend clinical cases both verbally and in writing during consultations, reviews, and formal hearings.

• Strong understanding of clinical best practices with the ability to apply evidence-based standards in alignment with state regulations, accreditation requirements, and contractual guidelines.

Preferred Qualifications and Experience

• Ability to build and maintain strong, professional working relationships.
• Demonstrated effectively in a team-oriented environment, contributing to shared goals and collective accountability.

• Excellent verbal and written communication skills, with the ability to effectively engage individuals from diverse professional, cultural, and educational backgrounds.

• Strong professional telephone presence and communication proficiency.

• Ability to manage multiple priorities simultaneously while maintaining organization, adaptability, and high-quality outcomes in a fast-paced environment.

• Exceptional attention to detail with a strong commitment to accuracy and quality.

• Advanced data entry and documentation skills with a focus on precision and timeliness.

• Proficiency in Microsoft Office applications, including Word, Excel, and Outlook.

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 nationwide. Our company cares about our employees, giving you the tools and encouragement, you need to achieve the finest work of your career.

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!

EOE 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, gender identity, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

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.

Compensation

The compensation for this role is $67,800.00 to $77,000.00 annual base salary

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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