Medical Reviewer for Healthcare Compliance
7 days ago
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:
- Perform comprehensive reviews of medical records and healthcare claims to determine accuracy and compliance with regulatory requirements.
- Analyze and interpret complex medical data, including CDT, CPT, ICD, DRG, REV, and HCPCS coding systems.
- Conduct research and gather information to support findings and recommendations.
- Prepare detailed reports summarizing review results, including recommendations for corrective action.
- 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.
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