Medical Reviewer – Special Investigations Unit
IEHP
full-time
Posted on:
Location Type: Hybrid
Location: Rancho Cucamonga • California • 🇺🇸 United States
Visit company websiteSalary
💰 $71,573 - $93,038 per year
Job Level
JuniorMid-Level
About the role
- Perform reviews of medical records and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations.
- 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.
- Conduct research relevant to issues under review.
- 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.
- Apply knowledge of healthcare coding conventions, policies, and other areas of vulnerability.
- Support/participate in provider calls and reinforce medical review findings and provider education.
- Presents findings to leadership, regulators and law enforcement and assist in legal proceedings, as appropriate.
- Maintain knowledge of new and relevant regulations, standards, and coding guidelines.
- Identify inefficiencies in policies or processes and recommend improvements.
- Maintain confidentiality and discretion in all investigative activities.
- Support special projects and other duties as assigned.
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
- 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 or Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN
- 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
Benefits
- 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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
medical codingmedical billingICD codingCPT codingHCPCS codingDRG codingrevenue codesinvestigative processeshealthcare regulationsdata analysis
Soft skills
communication skillsinterpersonal skillsproblem-solving skillsattention to detailorganizational skillstime managementindependent workteam collaborationadaptabilityreport writing
Certifications
Certified Professional Coder (CPC)Certified Professional Medical Auditor (CPMA)Certified Coding Specialist (CCS)Vocational Nurse (LVN) licenseRegistered Nurse (RN) license