• Lead Medicaid Reviewer

    Job ID 2019-3290
    Job Locations
    Analyst (Business, Systems, Data)
    Regular Part-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.


    NCI: As a Lead Medicaid Reviewer (Medicaid Reviewer III), you will travel extensively with your team to scheduled states for Data Processing reviews. 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.

    • Extensive travel (air/car) – 60-75% per year - with your team to scheduled states for Data Processing reviews. Travel will generally be Sunday through Thursday and/or Friday based on workload. 
    • Develop performance standards and output standards for less experienced staff to meet CMS metrics/timeliness requirements.
    • Collaboratively work with Medicaid staff to set goals, develop processes, and set timelines
    • Independently works with state IT staff to gain access and troubleshoot problems that prevent access to state MMIS for direct reports.
    • Work one-to-one with less experienced reviewers to develop individualized standards involving claims processing, authorization, and payment; reviews individual outcomes against these standards; and collaboratively develops an individualized corrective plan if there are significant discrepancies with these standards.
    • Support experienced team members with review of exceptions and resolution of conflicting findings from lower level reviewers.
    • Research complex review situations and arrive at an accurate conclusion.
    • Review and analyze multiple claim processing, eligibility enrollment, and provider enrollment systems. Make an informed decision to determine if the information in all systems resulted in An accurate payment determination.
    • Consult with management and staff stakeholders the implication of how state and federal policies and regulations are applied in differing claims scenarios.
    • Read, interpret, and apply complex federal and state regulations and their impact to claim processing. Suggest revisions to any impacted work products or standard operating procedures as a result of changes in federal or state regulations impacting Medicaid claims payment accuracy.
    • Must be able to audit all phases of a claim and determine if all phases were processed accurately.  
    • Independently review claims to determine appropriateness of payment using state and federal policy. Among criteria to be reviewed includes, but is not limited to; beneficiary information, third-party liability, beneficiary liability, provider risk based screening, accurate claim payment, and duplicate claim submission. Correctly apply state policies, statutes, and regulations to the review criteria on each claim in the sample for all review criteria.  Review claims remotely to determine appropriateness of payment using state and federal policy - review bene info, review TPL, review provider info, review for correct payment, review for duplicates. Correctly apply federal statutes and regulations to the review criteria on each claim in the sample for all review criteria. Accurately and efficiently document all findings in SMERF for all levels of reviews.
    • Independently conduct periodic Claims Processing reviews to insure timely and accurate processing. Recommends corrective action to management & staff.
    • Investigates Claim Payment Systems and analyzes data to determine if systemic errors are occurring. Reports discrepancies and suggests corrective action to management to resolve the discrepancies.
    • Using review experience, determine what type of reports to build within the case management system to demonstrate both positive and negative trends in errors cited during reviews. Using these reports analyze the trends and determine potential causes for the increase or decrease in citations. Critically evaluate the trend and present theories to the management team, stakeholders, and customers to reverse negative trends and promote positive trends. Prepare reports as needed for both internal and external customers.
    •  Complete assignments in a manner that meets or exceeds the quality assurance goal for accuracy.
    • Maintain chain of custody on all documents and follows all confidentiality and security guidelines.



    • Bachelor’s Degree and 5 years experience, or equivalent work experience in lieu of degree
    • At least four (4) years’ experience in medical terminology and insurance claims payment system
    • At least four (4) years of Medicaid/CHIP experience
    • Must have and maintain a valid driver's license for the associate’s state of residence.
    • Must live within reasonable commuting distance of a major airport.


    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
    • Repeatedly lift and carry weight up to 15 pounds
    • Travel by land or air transportation 60-75 %


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