NCI: As the Medical Review Quality Assurance Nurse (Medical Reviewer, Senior) for AdvanceMed, a subsidiary of NCI, you will play an integral part in the continual quality improvement process, by performing Quality Assurance reviews of completed prepay and postpay medical reviews to ensure that they meet internal and external quality metrics. Through analysis of quality scores and trends, you will play an important part in identification of educational and process needs for the medical review team.
Highlights of Responsibilities:
Provides subject matter expertise and technical assistance for complex subject matters in the areas of the Medical Review (MR), Benefit Integrity (BI), and Data Analysis (DA).
Assists the MR, BI, DA staff by researching CMS coverage criteria, regulatory guidance, Medicare regulations, and Local and National Coverage Decisions as requested.
Performs other duties as assigned including special projects, demonstrating an in-depth understanding of MR needs in the CMS benefit integrity environment and providing leadership of these same qualities to other team members.
Provides peer leadership for other medical review staff through mentoring, on-site leadership, and hands-on training of research, medical review techniques and appropriate documentation.
Develops and oversees consistency activities, including Inter-Rater Reliability Reviews.
Utilizes extensive knowledge of medical terminology, ICD-9-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims.
Utilizes Medicare and Contractor guidelines for coverage determinations.
Provides monthly quality review scores to the management team.
Identifies training needs and/or conducts training for the medical review and benefit integrity staff as needed.
Assists in development of Quality Objectives and Standard Operating Procedures for the MR Unit.
Graduate from an accredited school of nursing.
An active license as a Registered Nurse (RN).
Advanced knowledge of utilization review/quality assurance procedures, ICD-9-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative (CCI), DRGs, PPS, ASC).
Experience reviewing medical claims to determine medical necessity and appropriateness.
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 §1154(b)(1) of the Social Security Act.
Proficiency in Microsoft products such as Word, Excel, Access, and PowerPoint at an intermediate level.
Preferred Education and Experience:
Experience in medical review for Benefit Integrity.
Bachelor’s Degree in a health related field.
At NCI, we’re more than just a paycheck…
We offer significant opportunity for growth at NCI – Adding more and more employees and company locations nationwide, we continue to seek top talent to ensure our path of innovation, growth and unmatched customer experience. We reward our employees with competitive compensation, flexible time off, retirement plan with company match and much more…
MEDICAL/DENTAL/VISION PROGRAMS - NCI offers three medical plan options to meet the personal health needs and budgets of our full-time employees and their families. All plans provide our employees and their eligible dependents with major medical and prescription drug coverage. The dental plan provides coverage options so as to ensure our full-time employees and their eligible dependents are able to follow a regularly scheduled program of dental care with their providers of choice. A vision maintenance plan offers a cost-savings option for our full-time employees and their families in need of comprehensive annual eye exams, prescription glasses, and contact lenses.
STOCK & WEALTH - NCI’s 401(k) Profit Sharing Plan is eligible to all full-time and regular part-time employees. Employees may elect to have contributions invested in any of the 15 different investment funds, five retirement-date-based funds, or three different portfolio options available under the plan. The company matching contribution is equal to 50% of employee elected pre-tax contributions up to 6% of eligible pay, subject to the IRS maximum.
LIFE INSURANCE - NCI provides company paid Basic Life/ AD&D Insurance Coverage. The basic coverage benefit is equal to one times (1X) an employee's annual base salary. Employees may also opt for a generous flat rate insurance coverage. For coverage above the company-provided limits, employees may purchase supplemental insurance coverage for themselves and their family members.
WORK/LIFE BALANCE - All employees are eligible for additional programs including Paid Time Off (PTO).
It is your turn… Choose your career path and become part of the NCI team where you will be valued for your unique skills and capabilities and where you will be rewarded for key contributions to NCI and our customers.
- Flexible Spending Programs
- Employee Assistance Program (EAP) for employees and their immediate family
- Health Club Reimbursement through NCI’s Wellness Program
Make the commitment and take the next step towards joining the NCI Team. Our application process will take approximately 5-10 minutes to complete.
If you do not meet the minimum qualifications for this position, please review our current openings now and in the future. Thank you for your interest in NCI!
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, sexual orientation, disability or veteran status.
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.
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