Medicaid Medical Review Subject Matter Expert  - REMOTE 

The Medicaid Medical Review SME will primarily be responsible for activities related to Medicaid Medical Review. 

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 healthcare delivery by identifying and eliminating fraud, waste and abuse.

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

At this time, CoventBridge is not considering candidates who require visa sponsorship, currently or in the future, including but not limited to H-1B, H-2B, E-3, TN, O-1, F-1 (OPT/CPT, or J-1 Visa Statuses.)

Responsibilities:

• Work closely with the Data Analysis and Program Integrity teams to ensure actionable proactive studies with ROI that meets CMS requirements
• Research state Medicaid regulations and policies and Medicaid managed care policies and manuals to establish criteria for medical review attributes
• Build Medical Review provider folders for assigning to reviewers to contain all information to complete the review that has been approved by the state partner and CMS
• Complete quality assurance on the Medicaid cases as assigned in Medical Review
• Finalize Medical Review criteria for submission to the states and CMS through the PI teams
• Help establish and maintain relationships with state Medicaid agencies and CMS
• Attend all Medicaid state partner meetings representing the Medical Review department
• Produce and submit required reports according to pre-established time guidelines
• Support team in meeting quality and production standards
• Ensure departmental compliance with Quality Management System and ISO requirements
• Perform other duties as assigned by the Medical Review Manager that contribute to task order goals and objectives

Requirements:

• Excellent written and verbal communication skills
• Strong Medicaid research abilities
• Ability to work independently and with minimal supervision
• Knowledge of statistics, data analysis techniques, and PC skills are preferred

Educational/Experience Qualifications:  

• Bachelor’s Degree or equivalent related experience
• Candidates who have graduated from an accredited school of nursing and have an active license as a Registered Nurse (RN) will be given priority consideration
• Minimum of four (4) years of experience in Medicaid fraud investigations including investigation development, data analysis, and problem identification or one (1) year of experience with an advanced degree

• 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 $75,000 to $85,000 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 Group is the global leader in full-service investigations providing Surveillance, SIU and Compliance, Claims Investigation, Counter-Fraud Programs, Desktop Investigations, Social Media, Record Retrieval, Canvasses and Vendor Management programs. The company provides top tier data privacy and security practices, deploys robust case management technology customized to clients’ needs and delivers worldwide coverage via its 1000 employees and affiliates worldwide.

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 and maintains a drug-free workplace.

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.

At this time, CoventBridge is not considering candidates who require visa sponsorship, currently or in the future, including but not limited to H-1B, H-2B, E-3, TN, O-1, F-1 (OPT/CPT, or J-1 Visa Statuses.)

https://coventbridge.com/licensing/

UPIC