NCI: As the Medicare Medical Review Registered Nurse (RN), you will be primarily responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives, such as requests for information or in support of proactive data analysis efforts. You will apply your Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage.
Highlights of Responsibilities:
- Reviews information contained in Standard Claims Processing System files (e.g., claims history, provider files) 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 and ICD-10, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare and Contractor guidelines for coverage determinations.
- Coordinates and compiles the written Investigative Summary Report to the PI Investigator upon completion of the records review.
- I ncorporates leadership and communication skills to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel.
- Provides training to UPIC staff on medical terminology, reading medical records, and policy interpretation.
- Provides expert witness testimony as required.
- Completes assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy.
- Maintains chain of custody on all documents and follows all confidentiality and security
- Performs other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations.
Preferred Education and Experience: facebook | Twitter | LinkedIn
- Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN).
- At least 2 years utilization/quality assurance review and ICD-9/10-CM/CPT-4 coding experience.
- Experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines is required.
- Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9/10-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required.
- A bility to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems.
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.
The information above has been designed to indicate the general nature and level of work performed by employees within the classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this position.
NCI is a leading provider of enterprise solutions and services to U.S. defense, intelligence, health and civilian government agencies. The company has the expertise and proven track record to solve its customers most important and complex mission challenges through technology and innovation. NCI's team of highly skilled professionals focuses on delivering cost-effective solutions and services in the areas of agile development and integration; cybersecurity and information assurance; engineering and logistics; big data and data analytics; IT infrastructure optimization and service management; and health and program integrity. Headquartered in Reston, Virginia, NCI has approximately 2,000 employees operating at more than 100 locations worldwide.
Work location: Detroit, MI