Medical Review Team Lead

This is a fully remote position, open to applicants in United States.

📋 Description

• Meet quality targets and manage workloads to ensure the timely development and resolution of medical reviews.

• Collaborate with the investigations team to prepare cases for referral to law enforcement or relevant entities.

• Provide mentorship and guidance to the medical review team.

• Investigate medical claims data and other information sources to pinpoint issues.

• Analyze complex data model outputs and utilize tools to identify potential fraud.

• Support ongoing fraud investigations and respond to information requests.

• Serve as a primary contact for the manager.

• Assist team members in developing workflows.

• Review individual workloads during monthly meetings, help prioritize tasks, and conduct quality control for staff.

• Oversee the quality of WMM/UCM.

• Track the timeliness of case updates and escalate issues to management as needed.

• Monitor the progress of investigations, audits, and cases.

• Guide team members in uncovering previously unnoticed fraud, waste, or abuse through research, analysis, review, and development.

• Present issues of concern, citing regulatory violations and alleged schemes or scams aimed at defrauding the Government.

• Make claim payment decisions based on clinical expertise.

• Coordinate with other designated leads to ensure coverage during their absence.

⛳️ Requirements

• A minimum of 8 years of experience with a BS/BA or 12 years with a HS Diploma/equivalent.

• Experience in the medical review field as a fraud, waste, and abuse Nurse or other clinician, and/or in the review of medical claims for coverage and medical necessity.

• Must possess a current and active nursing license.

• Strong investigative abilities.

• Excellent communication and organizational skills.

• Proficient PC knowledge and skills.

• Applicants must be U.S. citizens.

• Experience in reviewing claims for technical requirements, conducting medical reviews, and/or developing fraud cases.

• Familiarity with Medicaid requirements, laws, rules, and regulations related to service billing.

• CPC (Certified Professional Coder) certification.

• Proficiency in Spanish, both speaking and writing.

• Ability to testify in court regarding work findings.

• Capable of composing correspondence, reports, and referral summary letters.

• Effective communication skills, both internally and externally.

• Ability to manage confidential information.

• Timely reporting of work activities.

• Capacity to work independently as well as collaboratively in a team to deliver high-quality results.

• Ability to educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard issues.

• Competence in conducting research and drawing conclusions.

🏝️ Benefits

• Telework options available from anywhere within the United States.

• Overnight travel required for meetings, training sessions, and conferences.

• Potential eligibility for overtime, shift differential, and a discretionary bonus in addition to base salary.