NCI is a leading provider of enterprise solutions and services to U.S. defense, intelligence, health and civilian government agencies. Coupled with a refined focus on strategic partnerships, we are successfully bridging the gap between commercial best practices and mission-critical government processes. Core competencies include:
NCI has been designated a 2018 Military Friendly Employer by MilitaryFriendly.com
Headquartered in Reston, Virginia, NCI has approximately 2,000 employees operating at more than 100 locations worldwide.
Primarily responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. Applies Medicare/Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage.
Review information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare/Medicaid payment policies
Utilize extensive knowledge of medical terminology, ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilize Medicare/Medicaid and Contractor guidelines for coverage determinations
Coordinate and compile written Investigative Summary Reports in conjunction with PI Investigators upon completion of the records review
Uses leadership and communication skill to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel
Provide training to UPIC staff on medical terminology, reading medical records, and policy interpretation
Provide expert witness testimony as required
Complete assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy
Maintain chain of custody on all documents and follows all confidentiality and security guidelines
Perform other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations
Bachelor’s Degree with active state licensure or graduate from an accredited Registered Nurse (RN) school (Associate’s degree or diploma-based) or equivalent related experience
PREFERRED EDUCATION AND EXPERIENCE:
This position requires the ability to perform the below essential functions: