• Medical Review Subject Matter Expert

    Job ID 2018-2674
    Job Locations
    US-VA-Henrico | US-MD-Baltimore | US-OH-Grove City | US-TN-Nashville
    Program / Project Management
    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
    • Error rate reporting
    • 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.


    NCI: As the Medical Review Subject Matter Expert (Project Manager III) you will be in direct communication with the Medical Review Manager, Medical Reviewers, and the CMS PERM staff, as necessary to provide expert clinical guidance and technical assistance, ensuring adherence to the medical review function of the RC. The Medical Review Subject Matter Expert will possess extensive knowledge and proven ability to continually assesses and evaluate clinical compliance with relevant regulations, both at a state and federal level.




    • Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines.
    • Utilize electronic health information imaging and inputs medical review decisions by electronic database module.
    • Utilize internet and intranet sources for policy verification.
    • Utilize Microsoft Office suite and other software templates as associated source input for claims review.
    • Make clinical judgment decisions based on clinical experience when applicable.
    • Ability to keep sensitive and confidential material private.
    • Medical claim review experience.
    • Responsible for review of Medicaid/CHIP claims.
    • Supervising the analysis of provider and service specific claims to identify error.
    • Ensuring departmental compliance with quality managements system and ISO requirements.
    • Meeting quality and production standards.
    • Developing and implementing written procedures for the Medical Review unit.
    • Coordination with State Representatives regarding Medical Review-specific issues.




    • Bachelor's Degree in Nursing
    • A minimum of six (6) years’ experience practicing nursing as a licensed Registered Nurse;
    • A minimum of six (6) years’ experience in a supervisory/managerial role in the health insurance industry, a utilization review firm, or another health care claims processing organization involving medical and coding reviews of a variety of medical and surgical claims from a variety of provider types;
    • Extensive knowledge of state and federal healthcare regulations, policies, coverage guidelines, and reimbursement rules in making clinical determinations as to the medical necessity and appropriateness of services rendered and billed and corresponding payment determinations;
    • Extensive experience performing medical review and/or utilization/QA reviews;
    • Extensive knowledge of the Medicaid and/or CHIP program, particularly the coverage, conditions of payment, and state-specific policy requirements for health care coverage and payment; and
    • Must be a Registered Nurse (RN) in one or more of the 50 states of D.C.
    • CPC (Certified Professional Coder) required



    • Medicaid and/or CHIP medical review experience is preferred.
    • Demonstrated knowledge of ICD-10CM, CPT-4, and HCPCS Level II coding applications desirable (certification preferred).
    • For CHIP review, some pediatric nursing experience is preferred.
    • CPMA (Certified Professional Medical Auditor), CDIP (Certified Documentation Improvement Practitioner), RHIT (Registered Health Information Technician), CCS (Certified Coding Specialist), CCS-P (Certified Coding Specialist - Physician), or CCA (Certified Coding Associate) are preferred.
    • Inpatient InterQual/Milliman screening or similar product experience.
    • Optional – We will also need bilingual Medical Reviewers to accommodate the review of Spanish medical records.




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