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 anauthentic 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.PerksIEHP 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 salaryHybrid scheduleState of the art fitness center on-siteMedical Insurance with Dental and VisionLife, short-term, and long-term disability optionsCareer advancement opportunities and professional developmentWellness programs that promote a healthy work-life balanceFlexible Spending Account - Health Care/ChildcareCalPERS retirement457(b) option with a contribution matchPaid life insurance for employeesPet care insurancePerform 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.Education & Requirements A minimum of two (2) years of experience performing medical reviews of medical records and claims in a healthcare settingBachelor’s degree in Medical Billing/Medical Coding, Nursing, Healthcare Administration, or related field from an accredited institution requiredIn lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this positionThis experience is in addition to the minimum years listed in the Experience Requirements aboveCertified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) requiredOne 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 TechniciansPossession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRNKey QualificationsMust have a valid California Driver’s licenseStrong understanding of medical coding, billing practices, and healthcare regulationsThorough understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDC’s and other guidelines and general understanding of investigative processes within a healthcare environment are requiredKnowledge of Medi-Cal and Medicare rules and regulations, and managed care in California is preferredStrong verbal and written communication, interpersonal skills, critical problem-solving skills, and attention to detailAbove average proficiency in the use of technology applications, particularly Excel, Word, and others as necessaryDetail-oriented with strong organizational and time management abilities. Ability to articulate medical review findings clearly and thoroughlyConduct research in support of medical reviews and make determinations on claims with a high level of accuracyDemonstrated ability to interpret and analyze healthcare data and recordsAdapt to different technology software and platforms, including anti-fraud solutionsAbility to work independently and collaboratively with a teamStart 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.)USD $71,572.80 - USD $93,038.40 /Yr.

Created: 2025-11-01