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
ESSENTIAL FUNCTIONS BY LEVEL:
MEDICAL REVIEWER V
Reviews and analyzes sampled Medicaid claims using associated medical records, to make payment determinations based on coverage, coding, utilization of services and practice guidelines
Makes medical necessity determinations utilizing clinical review judgment in accordance with PERM policies and contract responsibilities
Serves as a resource for medical review specialists involving coverage, coding, and medical necessity issues
Performs the first and secondlevel of medical review in determination of claims payment review
Conducts in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles
Provides medical review specialist production assignments (quantity and type of claim review) to the Medical record Department as needed
Provides medical review specialist claims production reports to the Medical Review Manager applying appropriate variance (fringe hours, QA, meeting time, etc.) statistics as needed
Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines, as well as local medical review policies
Provides research and updates to specialty claims review and review team needs
Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields
Provides training to integral staff and subcontractors for special studies as well as regular project claims review
Complies with departmental policies and procedures
Attends departmental or required education and training programs
Completes other projects or duties as assigned by the Medical Review Manager
Qualifications
MINIMUM REQUIREMENTS:
V
Graduate from an accredited Registered Nurse (RN) school (Associate's degree or diploma based) or Bachelor's Degree (preferred) with active state licensure
Excellent oral and written communication skills
Organization and time management skills
Leadership skills to guide and mentor the work of less experienced personnel
Interpersonal skills
Problem solving and analytical skills
Ability to work in a team environment
Ability to keep sensitive and confidential material private
Ability to implement the operational strategies and procedures that will help achieve the overall quality and production goals of the Medical Review unit
At least four (4) years of clinical experience in medical or surgical nursing
Medical claim review experience
Demonstrated knowledge of ICD-9CM, CPT-4, and HCPCS Level II coding applications desirable (certification preferred)
EXPERIENCE REQUIRED BY LEVEL:
V: 10 - 15 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:
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.
