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Senior Medical Reviewer

2 months ago

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

We are seeking a highly skilled and experienced Senior Medical Reviewer to join our Special Investigations Unit. As a key member of our team, you will be responsible for conducting clinical and complex reviews of medical records and healthcare claims to ensure compliance with federal and state regulations.

Key Responsibilities
  • Conduct thorough reviews of medical records and healthcare claims to identify coding errors and billing discrepancies
  • Substantiate or refute the accuracy and compliance of codes billed in relation to incidents of suspected healthcare fraud, waste, and abuse
  • Provide guidance and mentorship to junior medical reviewers
  • Collaborate with cross-functional teams to ensure effective and efficient review processes
  • Stay up-to-date with changing regulations and guidelines to ensure compliance
Requirements
  • Minimum of 5 years of experience in medical review and auditing
  • Bachelor's degree in Medical Billing/Medical Coding, Nursing, Healthcare Administration, or related field
  • Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) certification
  • Active, unrestricted, and unencumbered Vocational Nurse (LVN) or Registered Nurse (RN) license
  • Valid California Driver's License
Preferred Qualifications
  • Knowledge of Medi-Cal and Medicare rules and regulations, and managed care in California
  • Experience with investigative processes within a healthcare environment
What We Offer
  • Competitive salary and annual merit increase
  • CalPERS retirement plan
  • 457(b) option with contribution match
  • Generous paid time off and holidays
  • State-of-the-art fitness center on-site
  • Medical, dental, and vision insurance
  • Short-term and long-term disability options
  • Pet care insurance
  • Flexible Spending Account - Health Care/Childcare
  • Wellness programs and career advancement opportunities