Medical Review Team Lead – Medicaid

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

📋 Description

• Meet quality goals and manage workload to ensure prompt development and resolution of medical reviews.

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

• Provide mentorship and support to the medical review team.

• Analyze medical claims data and other resources to pinpoint issues.

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

• Serve as a primary contact for the manager.

• Assist colleagues in developing workflows and setting priorities.

• Review individual workloads during monthly meetings.

• Oversee WMM/UCM quality and the timeliness of case updates, escalating issues to management when necessary.

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

• Detect previously unnoticed fraud, waste, or abuse through research, analysis, review, and development.

• Present concerns, highlighting regulatory breaches and alleged schemes or scams aimed at defrauding the Government.

• Make decisions on claim payments based on clinical expertise.

• Facilitate communication between Medicaid medical review management and reviewers, including subcontractors.

• Prepare review packages for peer evaluations.

• Upload and download documents from subcontractor secure sites.

• Organize and participate in internal and external meetings regarding cases and reviews.

• Assign cases and update the case tracker.

⛳️ Requirements

• A minimum of 8 years of experience with a BS/BA or 12 years with a high school diploma/equivalent.

• Experience in the medical review field as a fraud, waste, and abuse nurse or another clinician, and/or experience in reviewing medical claims for coverage and medical necessity.

• A current and active nursing license.

• Strong investigative abilities.

• Excellent communication and organizational skills.

• Capability to apply Federal, State, and Managed Care Organization (MCO) regulations to claims under review.

• Proficient PC skills.

• Must be a U.S. citizen.

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

• Familiarity with Medicaid requirements, laws, rules, and regulations regarding payment for services billed to the program.

• CPC (Certified Professional Coder) certification is preferred.

• Ability to appear in court to testify regarding work findings.

• Skill in composing correspondence, reports, and referral summary letters.

• Ability to handle confidential information appropriately.

• Timely reporting of work activity is essential.

• Ability to work independently as well as collaboratively within a team.

• Willingness to attend meetings, training sessions, and conferences; overnight travel may be required.

• Strong research capabilities and the ability to draw conclusions from findings.

🏝️ Benefits

• Overtime eligibility may apply.

• Shift differentials may apply.

• Discretionary bonuses may apply.

• Opportunities and requirements for overnight travel.