Medical Reviewer for Healthcare Compliance

7 days ago


Rancho Cucamonga, California, United States Inland Empire Health Plan Full time

At Inland Empire Health Plan, we are dedicated to delivering high-quality healthcare services to our members. Our team is committed to promoting the well-being of our community, and we are seeking a skilled Medical Reviewer to join our Special Investigations Unit (SIU).

**Job Summary:**

  • We are looking for an experienced Medical Reviewer to perform thorough reviews of medical records and healthcare claims to ensure compliance with federal and state regulations.

The successful candidate will have a strong background in medical billing and coding, with excellent analytical and problem-solving skills. They will be responsible for reviewing medical records and claims, identifying potential issues, and recommending corrective actions to investigators.

Key Responsibilities:

  1. Perform comprehensive reviews of medical records and healthcare claims to determine accuracy and compliance with regulatory requirements.
  2. Analyze and interpret complex medical data, including CDT, CPT, ICD, DRG, REV, and HCPCS coding systems.
  3. Conduct research and gather information to support findings and recommendations.
  4. Prepare detailed reports summarizing review results, including recommendations for corrective action.
  5. Collaborate with investigators to develop and implement strategies to prevent and detect healthcare fraud, waste, and abuse.

Requirements:

  • Bachelor's degree in Medical Billing/Medical Coding, Nursing, Healthcare Administration, or related field from an accredited institution.
  • Minimum two years of experience in medical reviews, with a strong understanding of healthcare coding conventions and policies.
  • Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) certification required.
  • Strong analytical and problem-solving skills, with attention to detail and ability to work independently.

Benefits:

  • A competitive salary range of $34.41 - $39.57 per hour, depending on experience.
  • Opportunities for professional growth and development within a dynamic organization.
  • A collaborative and supportive work environment.
  • A comprehensive benefits package, including medical, dental, and vision insurance.
  • Paid time off, holidays, and sick leave.

Work Environment:

  • This position is located in Rancho Cucamonga, California, and requires a hybrid work schedule, with some remote work options available.


  • Rancho Cucamonga, California, United States CorVel Healthcare Corporation Full time

    At CorVel Healthcare Corporation, we're seeking a skilled Healthcare Utilization Review Specialist to join our team. This role plays a crucial part in ensuring the highest quality patient care while maintaining efficient cost management.


  • Rancho Cucamonga, California, United States Inland Empire Health Plan Full time

    Company Overview:Inland Empire Health Plan (IEHP) is a leading healthcare organization dedicated to healing and inspiring the human spirit. As a dynamic and innovative team, we strive to provide exceptional care and services to our members.Salary: $80,059.20 - $106,059.20 per yearJob Description:We are seeking an experienced Senior Special Investigations...


  • Rancho Cordova, California, United States Blue Shield of California Full time

    Job Overview">The Clinical Compliance Principal role at Blue Shield of California is a strategic position that oversees the development and maintenance of audit playbooks for regulatory compliance across multiple lines of business. This requires strong engagement with internal and external stakeholders to adapt to changing compliance requirements and manage...


  • Rancho Cucamonga, California, United States Channell Family Medical Group Inc Full time

    At Channell Family Medical Group Inc, we are seeking a highly skilled and dedicated Nurse Practitioner/Physician Assistant to join our team in a collaborative leadership role. Job SummaryThis is a full-time position that requires 3-5 years of experience in family practice. The ideal candidate will be proficient in medication-assisted treatment and have...


  • Rancho Cucamonga, California, United States Kindred Healthcare Full time

    Become an Environmental Services Aide at Kindred Hospital Rancho!We're seeking a reliable and detail-oriented individual to join our team as an Environmental Services Aide. In this role, you'll select cleaning materials, load service carts, and clean assigned areas to maintain a safe and healthy environment for our patients and staff.Your Key...


  • Rancho Cucamonga, California, United States Peter Holtz CPA Full time

    Job OverviewWe are seeking a highly skilled Tax Resolution Specialist to join our team at Peter Holtz CPA. As a key member of our tax planning and consulting services, you will play a vital role in assisting clients with tax-related issues and ensuring compliance with tax regulations.Key Responsibilities:Client Consultation: Meet with clients to understand...


  • Rancho Cucamonga, California, United States ProCare Therapy Full time

    Overview\We are seeking a dedicated LPN or LVN to join our team at ProCare Therapy and make a significant impact on students development and educational success. As an integral member of our healthcare organization, you will perform a variety of essential tasks within an educational setting, ensuring the health and well-being of students and supporting the...


  • Rancho Cucamonga, California, United States Channell Family Medical Group Full time

    Company OverviewChannell Family Medical Group is a leading healthcare provider dedicated to delivering exceptional patient care. We are seeking an experienced Advanced Medical Care Provider to join our team.Salary and BenefitsThe estimated annual salary for this position is $120,000 - $180,000 based on experience, with a comprehensive benefits package that...


  • Rancho Cucamonga, California, United States Channell Family Medical Group Inc Full time

    Job OverviewWe are seeking a highly skilled and dedicated Healthcare Support Professional to join our team at Channell Family Medical Group Inc. This role is ideal for individuals who are passionate about providing exceptional patient care and have a strong desire to work in a fast-paced medical environment.About the RoleThe successful candidate will be...


  • Rancho Cucamonga, California, United States Channell Family Medical Group Inc Full time

    Job OverviewThe Channell Family Medical Group Inc is seeking a skilled Medical Support Specialist to join our team. As a key member of our medical staff, you will be responsible for providing clinical and administrative support to our patients and healthcare providers.


  • Rancho Cucamonga, California, United States AMN Healthcare Full time

    Seeking a highly skilled Medical Orthopedic Therapist to join our team in Rancho Cucamonga, CA. Job SummaryThis is a 13-week contract opportunity for a licensed Physical Therapist with orthopedic experience. As a member of our multidisciplinary healthcare team, you will provide high-quality patient care while working collaboratively with other therapists and...


  • Rancho Cucamonga, California, United States RCMC Medical Center Full time

    Transform Lives as a Medical Weight Loss CoachWe're seeking an experienced Licensed Vocational Nurse (LVN) to join our dynamic team at RCMC Medical Center. As a Medical Weight Loss Coach, you will play a vital role in helping patients achieve their health and wellness goals.About the RoleThis is a part-time position available for Thursday, Friday, and...


  • Rancho Cucamonga, California, United States Apria Full time

    About the Role\We are looking for a highly motivated and detail-oriented Home Healthcare Service Technician to join our team at Apria Healthcare. As a key member of our home healthcare services, you will play a critical role in delivering and setting up medical equipment for patients in their homes.Your primary responsibilities will include:Delivering and...


  • Rancho Cucamonga, California, United States AMR Full time

    Emergency Medical Care SpecialistWe are seeking a skilled and compassionate Emergency Medical Care Specialist to join our team at AMR. As a Paramedic, you will provide advanced medical care and leadership in emergency situations while utilizing medical equipment and procedures.About the RoleAs an Emergency Medical Care Specialist, you will assess call...


  • Rancho Cordova, California, United States Blue Shield of California Full time

    Job OverviewWe are seeking a Senior Healthcare Utilization Specialist to join our team at Blue Shield of California.Job SummaryThe Senior Healthcare Utilization Specialist is responsible for reviewing inpatient stays and determining medical necessity in compliance with state and federal regulations. This role involves conducting clinical reviews, discharge...


  • Rancho Cordova, California, United States Blue Shield of California Full time

    Job SummaryIn this challenging and rewarding role as a Senior Utilization Management Nurse at Blue Shield of California, you will be responsible for reviewing inpatient stays to ensure medical necessity in compliance with state and federal regulations. Your expertise in clinical review, discharge planning, and presenting cases to the Medical Director will...


  • Rancho Cucamonga, California, United States Vituity Full time

    Vituity is seeking a Medical Director to lead our correctional health team in California. This is an exceptional opportunity for a physician leader to make a meaningful impact on the lives of inmates and staff while enjoying a fulfilling career.About Vituity: We are a 100% physician-owned partnership that values autonomy, local control, and a national system...


  • Rancho Cucamonga, California, United States AMR Full time

    Company Overview:Global Medical Response and its family of companies, including AMR, are dedicated to delivering high-quality medical care during emergency situations. Our teams work tirelessly to provide compassionate and professional service to our patients.Salary: $27.14 to $51.08 per hour, depending on experience (DOE)Job Description:We are seeking a...


  • Rancho Cucamonga, California, United States HealthCare Support Full time

    About Our CompanyHealthCare Support is a leading provider of healthcare services, dedicated to delivering exceptional care to our clients. We are committed to providing a supportive and inclusive environment for our employees and the individuals we serve.Job SummaryWe are seeking a highly skilled Behavioral Health Case Manager to join our team. This is an...


  • Rancho Cordova, California, United States Blue Shield of California Full time

    Job OverviewIn this role, you will be responsible for reviewing inpatient stays and ensuring medical necessity in compliance with state and federal regulations. This position involves conducting clinical reviews, discharge planning, and presenting cases to the Medical Director.We are seeking a Senior Utilization Management Nurse who is dedicated to...