• Senior Medical Review Specialist

    Job ID 2019-3324
    Job Locations
    US-MD-Baltimore | US-Remote
    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.


    NCI: As a Senior Medical Review Specialist (Medical Reviewer V) for AdvanceMed, an NCI Company, you will perform Medicaid/CHIP comprehensive medical record and claims review to make payment determinations.  Leadership and interpersonal skills to guide and mentor the work of less experienced personnel.  Perform projects or duties as assigned by the Medical Review Manager/SME.  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.




    • 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 and at least ten (10) years claims knowledge either from billing, reviewing, or processing --OR -- Associate's degree and at least twelve (12) years claims knowledge either from billing, reviewing, or processing --OR -- Diploma in Nursing and at least thirteen (13) years claims knowledge either from billing, reviewing, or processing.
    • At least ten (10) years federal and local policy applications in relation to insurance procedures for medical necessity.
    • At least four (4) years in a supervisory/management position.
    • At least four (4) years clinical experience in a medical/surgical setting.
    • Three (3) years clinical experience as a Registered Nurse.
    • Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
    • 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.



    • 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), CPC (Certified Professional Coder), 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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