• Medical Review Specialist III

    Job ID 2019-3179
    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
    • Error rate measurement
    • 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 a Medical Review Specialist III (Medical Reviewer III) for AdvanceMed, an NCI Company, you will perform Medicare comprehensive medical record and claims review to make payment determinations for Medicare DRG Inpatient Acute Hospital admissions.  Perform projects or duties as assigned by the Lead Medical Review Specialist.  You will serve as a critical component in meeting our mission of providing excellent services to our clients. Your experience ensures an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. In assuming this position, you will be a critical contributor to meeting NCI's mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.


     Highlights of  Responsibilities:

    • Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Inpatient Acute Hospital admissions (DRG reimbursed).
    • 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.
    • Responsible for review of Medicare DRG claims.
    • Supervising the analysis of provider and service specific claims to identify error.
    • Meeting quality and production standards.  
    • Ensuring departmental compliance with quality managements system and ISO requirements.



    • Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.   At least four (4) years claims knowledge either from billing, reviewing, or processing.
    • At least four (4) years clinical experience as a Registered Nurse.
    • Minimum four (4) years federal and local policy applications in relation to insurance procedures for medical necessity including the Two Midnight Rule in DRG acute inpatient hospital admissions.
    • Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
    • 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 and must have no conflict of interest (COI).
    • Must have and maintain a valid state driver’s license for the state of residence.


    Preferred Education and Experience: 

    • ICD-10-CM, PCS, CPT-4, coding knowledge
    • Prior work as a Medicare Contractor Medical Review Nurse
    • Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!

    Physical Requirements:


    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


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