|Job Locations||US-Remote | US-VA-Henrico|
|Category||Administration / Clerical|
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:
NCI has been designated a 2018 Military Friendly Employer byMilitaryFriendly.com
Headquartered in Reston, Virginia, NCI has approximately 2,000 employees operating at more than 100 locations worldwide.
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.
PREFERRED EDUCATION AND EXPERIENCE:.