Special Investigations Unit Medical Reviewer (Hybrid Work Schedule)

Inland Empire Health Plan•Rancho Cucamonga, CA

11d•Hybrid

About The Position

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). 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.

Requirements

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/Medical Coding, Nursing, Healthcare Administration, or related field from an accredited institution required
In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position
This experience is in addition to the minimum years listed in the Experience Requirements above
Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) required
Must have a valid California Driver's license
Strong understanding of medical coding, billing practices, and healthcare regulations
Thorough understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDC's and other guidelines and general understanding of investigative processes within a healthcare environment are required
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
Detail-oriented with strong organizational and time management abilities. Ability to articulate medical review findings clearly and thoroughly
Conduct research in support of medical reviews and make determinations on claims with a high level of accuracy
Demonstrated ability to interpret and analyze healthcare data and records
Adapt to different technology software and platforms, including anti-fraud solutions
Ability to work independently and collaboratively with a team

Nice To Haves

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
Knowledge of Medi-Cal and Medicare rules and regulations, and managed care in California is preferred

Responsibilities

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
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).
Incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.