Nurse Reviewer

NCI Information Systems, Inc. - Remote3.6

Full-time
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Responsibilities
NCI: As a Nurse Reviewer (Medical Reviewer III), you will conduct in-depth claims analysis utilizing ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II coding principles. 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:
Conducts in-depth claims analysis utilizing ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II coding principles
Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using Center for Medicare Services (CMS) and other national guidelines, as well as national and local coverage decision determinations
Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields
Reviews and completes the required number of claims reviews in accordance to pre-established production standards for the project
Produces and submits required reports according to established content and timeframes
Communicates internally with all levels of the group
Participates in Quality Assurance (QA) and IRR monitoring as requested
Complies with departmental policies and procedures
Complies with Program Integrity Manual (PIM) and Statement of Work (SOW) guidelines and CMS directives and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information
Attends departmental and required education and training programs
Performs other projects or duties as assigned by the Medical Review Supervisor or Manager
Reviews information contained in Standard Claims Processing System to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies
Utilizes extensive knowledge of medical terminology, ICD-9-CM, ICD-10, HCPCS Level II and CPT coding along with analysis and processing of Medicare/Medicaid claims
Utilizes the Medicare/Medicaid guidelines for coverage determinations
Prepares written and verbal communications, statistical documentation of finding and conclusions with recommendations for Task order management and the carrier to support development of medical policy
Performs in-depth research and investigation using the Internet and other tools, including data analysis tools
Coordinates and compiles the investigative summary report for the Program Integrity Analyst, upon completion of the records review, summarizing claims determinations and clinical observations based on the review of medical records
Incorporates leadership and communication skills to work with physicians and other health professionals as well as external regulatory agencies and law enforcement
Effectively communicates with the customer, stakeholders and employees
Conducts in-depth claims analysis of suspected over-utilizers who are suspect of fraudulent billing practices, including analysis of Standard Claims Processing files, to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and/or Medicaid payment policies
Utilizes Medicare and Contractor guidelines for coverage determinations
Prepares written and verbal communications, statistical documentation of findings and conclusions with recommendations
Provides expert witness testimony as required, maintains chain of custody on all documents, follows all confidentiality and security guidelines and completes assignments in a manner that meets or exceeds the contract quality assurance goals
Complies with the Program Integrity Manual and Statement of Work guidelines, CMS directives and regulations and contract established policies and procedures pertaining to integrity, fraud, overpayments, statistical sampling and the handling and disclosure of information
Serves as a medical information resource and provides training on medical terminology, the reading of medical records and policy interpretation for contract
Performs other duties as assigned that contributes to contract goals and objectives
Qualifications

Requirements:
Bachelor’s Degree with active state license or graduate from an accredited Registered Nurse (RN) school (Associate’s degree or diploma-based) or equivalent related experience
Excellent oral and written communication skills
Organization and time management skills
Leadership skills to guide and mentor the work of less experienced personnel
Interpersonal skills
Problem solving and analytical skills
Ability to work in a team environment
Ability to keep sensitive and confidential material private
Willingness to travel
Knowledge of and ability to use Microsoft Office and internet applications
At least seven (7) years of nursing experience
Experience working with medical procedures and techniques, emergency medical techniques such as cardiac pulmonary resuscitation (CPR) and first aid
Experience working with case management practices and providing health education programs
Active state license
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
At least four (4) years clinical experience in a medical/surgical setting
Medical review experience required, prefer prior ZPIC or UPIC work or similar. MAC experience favorable.

Physical Requirements:
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 25 pounds
Travel by land or air transportation 5-10 %

It is the policy of NCI to provide equal opportunity in recruiting, hiring, training, and promoting individuals in all job categories without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, gender identity, or any other protected class or category as may be defined by federal, state, or local laws or regulations. In addition, we affirm that all compensation, benefits, company-sponsored training, educational assistance, social, and recreational programs are administered without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, or gender identity. It is our firm intent to support equal employment opportunity and affirmative action in keeping with applicable federal, state, and local laws and regulations. NCI is aVEVRAA Federal Contractor.