Medical Review Team Lead - REMOTE 

The Medical Review Team Lead position will mentor new medical reviewers or medical reviewers new to a benefit type, by review of completed prepay and post-pay medical reviews in accordance with the requirements of the Internet Only Manuals (IOM), including the Program Integrity Manual, UPIC Statement of Work and Standard Operating Procedures and Medicaid rules and regulations. Support the Medical Review team by providing education and identifying training opportunities during mentoring process. Participate in on-site audits and ALJ hearings as needed.  

In assuming this position, you will be a critical contributor to meeting CoventBridge Group's objective:  To provide services to our clients that exceed their expectations and contribute to improved health-care delivery by identifying and eliminating fraud, waste and abuse.

This position will report directly to the Medical Review Supervisor and will work in our Grove City, OH office, or if not local, remotely from a home office. 

 Responsibilities:

• Analyze, evaluate, and conduct under the direction of the Medical Review Supervisor/Manager, medical review investigations, studies, and data review in accordance with the UPIC policies and contract responsibilities
• Assist in conducting reviews and mentoring staff at the same time
• Conduct in depth claim review of providers who are suspected of fraud, waste or abuse utilizing state Medicaid policies or Medicare regulations as applicable
• Utilize extensive knowledge of medical terminology, ICD-10, HCPCS and CPT coding in the analysis and processing of Medicaid or Medicare claims
• Utilize Medicare and Medicaid guidelines for coverage determinations
• Provide expert testimony as needed
• Serve as a medical information resource and provide training and interpretation for other UPIC staff
• Prepare reports and summarize claim determinations and clinical observations in pre-established timeframes
• Serves as the resource for medical reviewers for complex medical review issues
• Incorporates leadership and communication skills to work with other healthcare professionals internally and externally
• Coordinates with management on the resolution of complex cases
• Assist supervisor or manager in providing oversight for quality reviews
• Assists supervisor or manager with orientation of new staff to the company or new benefit type
• Comply with Program Integrity Manual (PIM) and Statement of Work (SOW) guidelines, CMS directives and regulations, and UPIC policies and procedures as related to integrity, fraud, overpayments, statistical sampling and the handling and disclosure of information
• Perform other duties as assigned by manager or Program Director that contribute to UPIC goals and objectives.

Requirements:

• Excellent verbal and written communication skills
• Proven organization and time management skills
• Leadership and teaching skills to educate others
• People skills
• Problem solving and analytical skills
• Ability to work in a team environment
• Ability to keep sensitive and confidential material private.
• Ability to prioritize workload to meet demands.
• Willingness to travel to assist with onsite audits.

Educational/Experience Qualifications:

• Bachelor’s Degree with active state licensure or graduate from an accredited Registered Nurse (RN) school (Associate Degree or diploma-based) or equivalent related experience.
• Minimum of 2 years in Medical Review at ZPIC or UPIC level of reviewing and meeting quality and production standards.
• Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program, and must have no conflict of interest (COI) as defined in Section 1154(b)(1) of the Social Security Act.

• Medical, Dental, Vision plans
• Life, LTD and STD paid by the employer
• 401(k) with company match up to 4%
• Paid Time Off and company paid holidays
• Tuition assistance after 1 year of service

The salary range for this role is $75k - $85k annually. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future.  An employee’s pay position within the salary range will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs.  

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

About Us:

CoventBridge is an equal opportunity employer.  We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics.

CoventBridge is committed to the full inclusion of all qualified individuals.  As part of this commitment, CoventBridge will ensure that persons with disabilities are provided reasonable accommodations.  If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact: Human Resources; 888-932-7364; humanresources@coventbridge.com).

https://coventbridge.com/licensing/