Senior Special Investigations Unit Medical Reviewer

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Under minimal supervision, the Senior Special Investigations Unit Medical Reviewer (Senior SIU Medical Reviewer) performs clinical and complex 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).  The Senior SIU Medical Reviewer will provide guidance and mentorship to SIU Medical Reviewers. 

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.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more.

• CalPERS retirement
• 457(b) option with a contribution match
• Generous paid time off- vacation, holidays, sick
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Paid life insurance for employees with additional options
• Short-term, and long-term disability options
• Pet care insurance
• Flexible Spending Account – Health Care/Childcare
• Wellness programs that promote a healthy work-life balance
• Career advancement opportunities and professional development
• Competitive salary with annual merit increase
• Team bonus opportunities

1. Perform clinical and complex reviews of medical records and healthcare claims to determine the accuracy and clinical necessity of codes billed against documentation provided in compliance with appropriate policies, procedures, and regulations.  
2. Understand, interpret, analyze, and make determinations concerning use of CDT, CPT, ICD, DRG, REV and HCPCS coding as it relates to potential healthcare FWA schemes.
3. Conduct medical policy and other research relevant to issues under review.
4. Prepare and submit detailed reports with the results of medical reviews, including corrective action recommendations to investigators. Recommendations may include determinations to deny, recover on overpaid claims, risk mitigations strategies, create internal process improvements or provide education to subjects under review. 
5. Apply knowledge of healthcare coding conventions, medical policies, fraud schemes and other areas of vulnerability. 
6. Partner with leader in leading provider calls to support medical review findings and educate providers.  
7. Present findings to leadership, regulators and law enforcement and assist in legal proceedings, as appropriate.
8. Provide training to SIU staff regarding medical records review and healthcare fraud trends.
9. Provide guidance to SIU Medical Reviewers, including training and mentoring on medical review processes, healthcare regulations, and coding practices.
10. Guide and mentor less experienced medical review staff.
11. Maintain knowledge of new and relevant regulations, standards, and coding guidelines.
12. Identify inefficiencies in policies or processes and assist with implementing improvements. 
13. Maintain confidentiality and discretion in all investigative activities.
14. Support special projects and other duties as assigned.

Education & Experience

• A minimum of five (5) years of experience performing medical reviews in support of a healthcare Special Investigations Unit. 

• 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.
• One of the following licenses required:
  • 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.
• Must have a valid California Driver's License

Key Qualifications

• In-depth knowledge of medical coding, billing practices, and healthcare regulations. In-depth 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. Knowledge of Medi-Cal and Medicare rules and regulations, and managed care in California is preferred.  

Start your journey towards a thriving future with IEHP and apply TODAY!

This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA)