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 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.

Perks

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

• 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

1. Perform reviews of medical records and healthcare claims, determining the accuracy of codes billed and 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 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 mitigation strategies, create internal process improvements or provide education to subjects under review.
5. Apply knowledge of healthcare coding conventions, policies, and other areas of vulnerability.
6. Support/participate in provider calls and reinforce medical review findings and provider education.
7. Presents findings to leadership, regulators and law enforcement and assist in legal proceedings, as appropriate.
8. Maintain knowledge of new and relevant regulations, standards, and coding guidelines.
9. Identify inefficiencies in policies or processes and recommend improvements.
10. Maintain confidentiality and discretion in all investigative activities.
11. Support special projects and other duties as assigned.

Education & 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
• 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

Key Qualifications

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

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.)