Senior Special Investigations Unit Medical Reviewer

Company: Inland Empire Health Plan
Location: Rancho Cucamonga
Posted on: March 6, 2025

Job Description:

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.PerksIEHP 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 retirement457(b) option with a contribution matchGenerous paid time off- vacation, holidays, sickState of the art fitness center on-siteMedical Insurance with Dental and VisionPaid life insurance for employees with additional optionsShort-term, and long-term disability optionsPet care insuranceFlexible Spending Account - Health Care/ChildcareWellness programs that promote a healthy work-life balanceCareer advancement opportunities and professional developmentCompetitive salary with annual merit increaseTeam bonus opportunitiesEducation & ExperienceA 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 LicenseKey QualificationsIn-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!

Keywords: Inland Empire Health Plan, Rancho Cucamonga , Senior Special Investigations Unit Medical Reviewer, Other , Rancho Cucamonga, California