Special Investigations Unit Medical Reviewer Rancho Cucamonga, CA

Special Investigations Unit Medical Reviewer job at Inland Empire Health Plan. Rancho Cucamonga, CA.

* 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.

This role offers an opportunity for dedicated healthcare professionals to contribute to high‑stakes investigations while utilizing their extensive clinical expertise across multiple disciplines in a dynamic environment.

• A minimum of two (2) years of experience performing medical reviews of medical records and claims in a healthcare setting
• 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
• 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
  • Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing

• Proven experience in hospital or clinical settings with expertise in multiple specialties including cardiology, neurology, endocrinology, nephrology, pediatrics, obstetrics/gynecology (Ob/Gyn), orthopedics, or trauma medicine.
• Familiarity with advanced diagnostic radiology techniques such as diagnostic radiology and neuroradiology.
• Experience working with EMR/EHR systems like Epic or similar platforms; proficiency in medical coding (ICD/CPT) is preferred.
• Background in clinical research or post‑acute care is advantageous.
• Knowledge of healthcare regulations including HIPAA standards and NCQA requirements.
• Strong understanding of medical terminology, physiology knowledge, and patient assessment procedures.
• Prior experience in telehealth services or outpatient/inpatient care environments is desirable.

• Must have a valid California Drivers license
• Strong understanding of medical coding, billing practices, and healthcare regulations
• Thorough understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDCs 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

This is a
* Hybrid* work schedule, with 3 onsite days at our main campus in the city of Rancho Cucamonga, CA.

Job Type: Full‑time

Projected Total Compensation: $71,572.80 - $93,038.40 per year

• 457(b)
• Dental insurance
• Flexible spending account
• Health insurance
• Loan repayment program
• Paid time off
• Retirement plan
• Travel reimbursement
• Vision insurance

Work Location:

Hybrid remote in Rancho Cucamonga, CA 91730