NCI: As the Medical Review Part B and DME Clinical Information Specialist (Medical Reviewer, Sr.) for AdvanceMed, a premier provider of healthcare program integrity services, you will provide mentoring and research assistance to the medical review, benefit integrity, and data analysis teams. In this position, your Medicare Part B and DME medical review skills will be used and will grow as you review claims, develop training and processes, and assist in quality reviews. In this role, you will be a critical contributor in meeting AdvanceMed’s mission, “To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste, and abuse."
Highlights of Responsibilities:
- Primarily responsible for conducting complex clinical or coding (CPT-4 and ICD-9-CM) reviews of medical records during the course of fraud investigations or other benefit integrity initiatives such as requests for information or in support of proactive data analysis efforts.
- 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.
- Incorporates leadership and communication skills to work with staff, physicians and other health professionals as well as external regulatory agencies and law enforcement personnel.
- Applies Medicare guidelines in addition to an advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims in making determinations as to the appropriateness of payment coverage.
- Provides expert witness testimony as required. Maintains chain of custody on all documents and follows all confidentiality, security and conflict of interest guidelines.
- Performs other duties as assigned by Management that contribute to ZPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations.
Preferred Education and Experience:
- Bachelor’s degree in healthcare or equivalent combination of education and experience.
- Minimum of 4 years clinical experience or equivalent experience in the Medical Review field.
- Active license as a Registered Nurse (RN) or Registered Record Administrator.
- 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.
- Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims.
- Proficiency with Microsoft Word, Excel and Internet applications at an intermediate level.
- Previous Medicare Medical Review experience.
- Bachelor’s degree in healthcare or 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).
- Flexible Spending Programs
- Employee Assistance Program (EAP) for employees and their immediate family
- Health Club Reimbursement through NCI’s Wellness Program
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.
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.