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 IEHPs Compliance Special Investigations Unit (SIU).
Commitment to Quality: The IEHP Team is committed to incorporate IEHPs Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
Additional Benefits: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.
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 & Experience
Bachelors 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.
Key Qualifications
Start your journey towards a thriving future with IEHP and apply TODAY !
Work Model Location:This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA)
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