Medical Review Team Lead

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. Support the Medical Review team by providing education and identifying training opportunities during mentoring process and participate in on-site audits and ALJ hearings as needed. 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. 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.