• Medical Review Nurse

    Job ID 2018-2659
    Job Locations
    Healthcare / Biotechnology
    Regular Full-Time
  • Overview

    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:

    • Artificial intelligence
    • Agile digital transformation
    • Advanced analytics
    • Hyperconverged infrastructure solutions
    • Cyber security and information assurance
    • Fraud, waste and abuse
    • Engineering and logistics


    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


    • At least 4 years’ utilization/quality assurance review and ICD-9/10-CM/CPT-4 coding experience


    • At least 4 years’ experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines is required
    • Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9/10-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required
    • Ability to read Medicare/Medicaid claims, both paper and electronic, and a basic knowledge of the Medicare/Medicaid claims systems is required
    • Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program and must have no conflict of interest (COI) as defined in Section 1154(b)(1) of the Social Security Act
    • Must have and maintain a valid state driver’s license for the state of residence






    • Medical claim review experience is required, prefer fraud, waste and abuse review experience.




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

    • Sitting for long periods
    • Standing for long periods
    • Ambulate throughout an office
    • Ambulate between several buildings
    • Stoop, kneel, crouch, or crawl as required
    • Repeatedly lift and carry weight up to _20__ pounds
    • Travel by land or air transportation _10__ %


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