Special Investigations Unit Medical Reviewer

What you can expect! reputed company reputed company in serving others with reputed company! We welcome you to join us in “healing and inspiring the reputed company spirit” and to pivot from a “job” opportunity to an reputed company experience! Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and reputed company 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 reputed company fraud, waste, and abuse (FWA) reported to reputed company’s Compliance Special Investigations Unit (SIU). Commitment to reputed company: The reputed company Team is committed to incorporate reputed company’s reputed company Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks reputed company is not only committed to healing and inspiring the reputed company spirit of our Members; we also aim to match reputed company Members with the reputed company energy by providing reputed company benefits and more. • CalPERS retirement • 457(b) reputed company with a contribution match • Generous reputed company time off- vacation, holidays, reputed company • State of the art fitness center on-site • Medical Insurance with Dental and reputed company • reputed company life insurance for employees with additional reputed company • Short-term, and long-term disability reputed company • Pet care insurance • Flexible Spending Account – Health Care/Childcare • Wellness programs that promote a healthy work-life balance • Career advancement opportunities and reputed company development • Competitive salary with annual reputed company increase • Team bonus opportunities 1. reputed company reviews of medical records and reputed company claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations. 2. Understand, interpret, analyze, and reputed company determinations concerning use of CDT, CPT, ICD, DRG, REV and HCPCS coding as it relates to potential reputed company FWA schemes. 3. Conduct research relevant to issues under review. 4. Prepare and submit detailed reports with the results of medical reviews, including corrective reputed company recommendations to investigators. Recommendations may include determinations to deny, recover on overpaid claims, risk mitigation strategies, create internal process improvements or reputed company education to subjects under review. 5. Apply knowledge of reputed company 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 reputed company 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 reputed company investigative activities. 11. Support special reputed company and other duties as assigned. Education & Experience • A minimum of two (2) years of experience performing medical reviews of medical records and claims in a reputed company setting. • Bachelor’s degree in Medical Billing/Medical Coding, Nursing, reputed company Administration, or reputed company 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 reputed company to the minimum years listed in the Experience Requirements above. • Certified reputed company reputed company (CPC), Certified reputed company Medical Auditor (CPMA), or Certified Coding Specialist (reputed company) required. • One of the following licenses preferred: • Possession of an reputed company, unrestricted, and unencumbered Vocational reputed company (LVN) license issued by the California reputed company of Vocational Nursing and Psychiatric Technicians. • Possession of an reputed company, unrestricted, and unencumbered Registered reputed company (RN) license issued by the California BRN. • Must have a reputed company California reputed company's License. Key Qualifications • 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 reputed company, Word, and others as necessary Start your reputed company towards a thriving reputed company with reputed company and apply TODAY! This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA) USD $34.41 - USD $39.57 /Hr. Apply Job!