Special Investigations Unit Medical Reviewer

2 weeks ago

Rancho Cucamonga CA United States Inland Empire Health Plan Full time
What you can expect

Find joy in serving others with IEHP We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience

Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and healthcare claims to substantiate or refute the accuracy and compliance with federal and state regulations and contractual requirements of codes billed to identify coding errors and billing discrepancies in relation to incidents of suspected healthcare fraud, waste, and abuse (FWA) reported to IEHP’s Compliance Special Investigations Unit (SIU).

Key Responsibilities:

1. Perform reviews of medical records and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations.
2. Understand, interpret, analyze, and make determinations concerning use of CDT, CPT, ICD, DRG, REV and HCPCS coding as it relates to potential healthcare FWA schemes.
3. Conduct research relevant to issues under review.
4. Prepare and submit detailed reports with the results of medical reviews, including corrective action recommendations to investigators. Recommendations may include determinations to deny, recover on overpaid claims, risk mitigation strategies, create internal process improvements or provide education to subjects under review.
5. Apply knowledge of healthcare coding conventions, policies, and other areas of vulnerability.
6. Support/participate in provider calls and reinforce medical review findings and provider education.
7. Presents findings to leadership, regulators and law enforcement and assist in legal proceedings, as appropriate.
8. Maintain knowledge of new and relevant regulations, standards, and coding guidelines.
9. Identify inefficiencies in policies or processes and recommend improvements.
10 . Maintain confidentiality and discretion in all investigative activities.
11. Support special projects and other duties as assigned.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more.

CalPERS retirement
457(b) option with a contribution match
Generous paid time off- vacation, holidays, sick
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Paid life insurance for employees with additional options
Short-term, and long-term disability options
Pet care insurance
Flexible Spending Account – Health Care/Childcare
Wellness programs that promote a healthy work-life balance
Career advancement opportunities and professional development
Competitive salary with annual merit increase
Team bonus opportunities

Education & Experience

A minimum of two (2) years of experience performing medical reviews of medical records and claims in a healthcare setting
Bachelor’s degree in medical billing or medical coding, nursing, healthcare administration, or other related field from an accredited institution required
Certified Professional Coder (CPC) required
One of the following licenses preferred
Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN

Key Qualifications

Strong verbal and written communication, interpersonal skills, critical problem-solving skills, and attention to detail
Above average proficiency in the use of technology applications, particularly Excel, Word, and others as necessary

Start your journey towards a thriving future with IEHP and apply TODAY

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