IEHP
Special Investigations Unit Medical Reviewer
IEHP, Rancho Cucamonga, California, United States, 91739
Special Investigations Unit Medical Reviewer
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. The review identifies coding errors and billing discrepancies related to incidents of suspected healthcare fraud, waste, and abuse (FWA) reported to IEHP’s Compliance Special Investigations Unit.
Perks
Competitive salary
Hybrid schedule
State‑of‑the‑art fitness center on‑site
Medical Insurance with Dental and Vision
Life, short‑term, and long‑term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work‑life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance
Education & Requirements
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; this experience is in addition to the minimum years listed above
Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) required
One of the following licenses preferred:
Licensed Vocational Nurse (LVN) active, unrestricted, and unencumbered issued by the California Board of Vocational Nursing and Psychiatric Technicians
Licensed Registered Nurse (RN) active, unrestricted, and unencumbered issued by the California BRN
Key Qualifications
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; general understanding of investigative processes within a healthcare environment required
Knowledge of Medi‑Cal and Medicare rules and regulations, and managed care in California preferred
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
Pay Range
$71,572.80 USD Annually – $93,038.40 USD Annually
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Perks
Competitive salary
Hybrid schedule
State‑of‑the‑art fitness center on‑site
Medical Insurance with Dental and Vision
Life, short‑term, and long‑term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work‑life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance
Education & Requirements
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; this experience is in addition to the minimum years listed above
Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) required
One of the following licenses preferred:
Licensed Vocational Nurse (LVN) active, unrestricted, and unencumbered issued by the California Board of Vocational Nursing and Psychiatric Technicians
Licensed Registered Nurse (RN) active, unrestricted, and unencumbered issued by the California BRN
Key Qualifications
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; general understanding of investigative processes within a healthcare environment required
Knowledge of Medi‑Cal and Medicare rules and regulations, and managed care in California preferred
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
Pay Range
$71,572.80 USD Annually – $93,038.40 USD Annually
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