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| Job Locations | US-Remote | US-VA-Henrico |
| Category | Administration / Clerical |
| Type | Regular Full-Time |
For more than 30 years, NCI Information Systems has been a leading provider of digital transformation solutions and services to U.S. government agencies. With its Empower platform, NCI is at the forefront of implementing artificial intelligence (AI) solutions to solve the government's most complex mission challenges. Headquartered in Reston, Va., NCI is accelerating public sector AI adoption to create a government workforce that is exponentially more creative and productive. For more information, visit www.nciinc.com.
As a Medical Review Nurse (Medical Reviewer IV) for NCI working on the CMS Medicare Hearings and Appeals Support (HAS) contract, you will perform medical review of appealed CMS Hierarchical Condition Codes (HCC) audit results and provide analysis of supporting documentation. In addition, you will be required to provide a written summary of findings to the CMS Hearings Officer as well as attending review and other meetings as requested by the hearings officer.
HIGHLIGHTS OF RESPONSIBILITIES:
* Review appealed CMS Hierarchical Condition Codes (HCC) audit results and supporting documentation and preparing a report that contains analysis and conclusions summarized
* Participate in decision conferences as requested by the CMS Hearing Officer
* Review Reconsideration Determinations, MA organization's justifications within its request for hearing and arguments within the parties' briefs and the enrollee's medical record for the audited CMS-HCC.
* Provide a written analysis for each appealed HCC, regarding whether the disputed diagnosis is expressly documented in the appealed medical record.
* Draft a recommendation regarding whether the disputed CMS-HCC and its underlying diagnosis code is expressly contained within the medical record and document whether another diagnosis code that maps to the appealed CMS-HCC is contained within the medical record. The MR nurse shall fully explain the reasons for the findings contained within the recommendation.
* 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.
* Ensuring departmental compliance with quality managements system and ISO requirements.
* Meeting quality and production standards.
REQUIREMENTS:
- Bachelor's degree or a minimum of 7-12 years experience
- A minimum of 2 years of experience reviewing medical documentation in relationship to services billed.
- Ability to keep sensitive and confidential material private.
- 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).
PREFERRED EDUCATION AND EXPERIENCE:.
- HCC coding or review experience preferred
- Medicare Advantage experience preferred
- CPC (Certified Professional Coder), CCS (Certified Coding Specialist), CCS-P (Certified Coding Specialist - Physician), or CCA (Certified Coding Associate) are preferred.
- Bilingual (Spanish) is a plus- Fluency in speaking, reading and understanding the Spanish language.
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 a VEVRAA Federal Contractor.
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.