Medical Reviewer

Job ID

2021-5883

Overview

For more than 30 years, NCI Information Systems has been a leading provider of digital transformation solutions and services to U.S. government agencies. With its NCI Empower Platform, NCI is at the forefront of implementing artificial intelligence (AI) solutions to solve the government's most complex mission challenges. Headquartered in Reston, Va., NCI is accelerating public sector AI adoption to create a government workforce that is exponentially more creative and productive. For more information, visit www.nciinc.com.

Responsibilities

MEDICAL REVIEWER III

Develops, approves, implements and ensures department compliance with Medical Review policies and procedures
• Ensures the MR department's compliance with quality management system and ISO requirements


• Effectively communicates with stakeholders, management, and colleagues.


• Performs other projects and responsibilities as assigned by the Medical Review Manager


• Utilizes extensive knowledge of medical terminology, ICD-9-CM, HCPCS Level II and CPT coding along with analysis and processing Medicaid claims


• Utilizes payer guidelines for coverage determinations


• Reviews the Master Policy List and the MR questionnaire for each State prior to the review of claims for that State


• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields


• Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment as defined by the Statement of Work and CMS directives as well as State specific regulations pertaining to Medical necessity


• Participates in QA and IRR monitoring as requested


• Complies with departmental policies and procedures


• Comply with QA and productivity benchmarks established by the PERM MR department


• Performs other projects or duties as assigned by the Senior Medical Review Specialist

Qualifications

MINIMUM REQUIREMENTS:

• Bachelor's Degree with active RN state licensure


• At least four (4) years clinical experience in a medical/surgical setting or conducting medical record reviews


• Problem solving and analytical skills


• Ability to work in a team environment


• Ability to keep sensitive and confidential material private


• Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program

EXPERIENCE REQUIRED BY LEVEL:

• III: 4 - 9 Years

PREFERRED EDUCATION AND EXPERIENCE:

• Medical claim review experience is desirable



• Active professional coding certification

PHYSICAL REQUIREMENTS:

This position requires the ability to perform the below essential functions:

(Hiring Manager: the below physical requirements are examples; please ensure you edit these to make them position specific for the job posting then remove this reminder reference)

• Sitting for long periods

About NCI

It is the policy of NCI to provide equal opportunity in recruiting, hiring, training, and promoting individuals in all job categories without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, gender identity, or any other protected class or category as may be defined by federal, state, or local laws or regulations. In addition, we affirm that all compensation, benefits, company-sponsored training, educational assistance, social, and recreational programs are administered without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, or gender identity. It is our firm intent to support equal employment opportunity and affirmative action in keeping with applicable federal, state, and local laws and regulations. NCI is a VEVRAA Federal Contractor.

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