DOJ Medical Record Review Nurse
SunIRef:
Nurse:
title Overview:
NCI is a leading provider of enterprise solutions and services to US defense, intelligence, health and civilian government agencies.
NCI's AI solution, Shai(tm), scales humans with artificial intelligence by empowering the workforce to meet their mission by using best in class AI solutions coupled with our exceptional service offerings.
Working with strategic partners, NCI is committed to bringing commercial innovation to missions of national importance.
NCI is a mid-tier systems integrator headquartered in Reston, VA, and operates at locations across the globe.
NCI has been designated a 2020 Military Friendly Employer by
Responsibilities:
NCI:
As a Nurse Reviewer (Medical Reviewer III), you will review and analyze Medicare claims sampled by the Department of Justice, using associated medical records, to make payment determinations based on coverage, coding and utilization of services and practice guidelines.
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.
Conducts medical record claims review to determine correct coding, utilizing ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II coding principles.
Review medical documentation for medical necessity utilizing clinical knowledge and Center for Medicare Services (CMS) policies and guidelines, as well as other state and board regulations.
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 Completes summary report upon completion of the records review, summarizing claim determinations, clinical observations and other information requested by the DOJ based on the review of medical records 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 Medicare and DOJ guidelines and CMS directives, policies and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information Attends departmental and required education and training programsReviews 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 the Medicare/Medicaid guidelines for coverage determinations Performs in-depth research and investigation using the Internet and other tools, including data analysis tools 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
Qualifications:
Requirements:
Registered Nurse (RN) ( Bachelors, Associate's degree or diploma-based) with active RN license Excellent oral and written communication skills Organization and time management skills Knowledge of and ability to use Microsoft Excel and word, Adobe PDFs and various internet applications At least 4 years of clinical experience 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 Medical review experience required Previous fraud review/ investigation experience preferred Physical Requirements:
This position requires the ability to perform the below
Essential Functions:
Sitting for long periods.
Estimated Salary: $20 to $28 per hour based on qualifications.
Nurse:
title Overview:
NCI is a leading provider of enterprise solutions and services to US defense, intelligence, health and civilian government agencies.
NCI's AI solution, Shai(tm), scales humans with artificial intelligence by empowering the workforce to meet their mission by using best in class AI solutions coupled with our exceptional service offerings.
Working with strategic partners, NCI is committed to bringing commercial innovation to missions of national importance.
NCI is a mid-tier systems integrator headquartered in Reston, VA, and operates at locations across the globe.
NCI has been designated a 2020 Military Friendly Employer by
Responsibilities:
NCI:
As a Nurse Reviewer (Medical Reviewer III), you will review and analyze Medicare claims sampled by the Department of Justice, using associated medical records, to make payment determinations based on coverage, coding and utilization of services and practice guidelines.
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.
Conducts medical record claims review to determine correct coding, utilizing ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II coding principles.
Review medical documentation for medical necessity utilizing clinical knowledge and Center for Medicare Services (CMS) policies and guidelines, as well as other state and board regulations.
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 Completes summary report upon completion of the records review, summarizing claim determinations, clinical observations and other information requested by the DOJ based on the review of medical records 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 Medicare and DOJ guidelines and CMS directives, policies and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information Attends departmental and required education and training programsReviews 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 the Medicare/Medicaid guidelines for coverage determinations Performs in-depth research and investigation using the Internet and other tools, including data analysis tools 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
Qualifications:
Requirements:
Registered Nurse (RN) ( Bachelors, Associate's degree or diploma-based) with active RN license Excellent oral and written communication skills Organization and time management skills Knowledge of and ability to use Microsoft Excel and word, Adobe PDFs and various internet applications At least 4 years of clinical experience 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 Medical review experience required Previous fraud review/ investigation experience preferred Physical Requirements:
This position requires the ability to perform the below
Essential Functions:
Sitting for long periods.
Estimated Salary: $20 to $28 per hour based on qualifications.
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