NashvilleTNRecruiter
the smart solution for Nashville jobs

Medical Review Subject Matter Expert with Security Clearance

Company: NCI Information Systems, Inc.
Location: Nashville
Posted on: November 17, 2018

Job Description:

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: * Artificial intelligence * Agile digital transformation * Advanced analytics * Hyperconverged infrastructure solutions * Cyber security and information assurance * Error rate reporting * Fraud, waste and abuse * Engineering and logistics MF18 NCI has been designated a 2018 Military Friendly Employer by MilitaryFriendly.com Headquartered in Reston, Virginia, NCI has approximately 2,000 employees operating at more than 100 locations worldwide. Responsibilities NCI: -- As the Medical Review Subject Matter Expert (Project Manager III) you will be in direct communication with the Medical Review Manager, Medical Reviewers, and the CMS PERM staff, as necessary to provide expert clinical guidance and technical assistance, ensuring adherence to the medical review function of the RC. The Medical Review Subject Matter Expert will possess extensive knowledge and proven ability to continually assesses and evaluate clinical compliance with relevant regulations, both at a state and federal level. HIGHLIGHTS OF RESPONSIBILITIES: -- * Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines. * 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. * Ability to keep sensitive and confidential material private. * Medical claim review experience. * Responsible for review of Medicaid/CHIP claims. * Supervising the analysis of provider and service specific claims to identify error. * Ensuring departmental compliance with quality managements system and ISO requirements. * Meeting quality and production standards. * Developing and implementing written procedures for the Medical Review unit. * Coordination with State Representatives regarding Medical Review-specific issues. Qualifications REQUIREMENTS: -- * Bachelor's Degree in Nursing * A minimum of six (6) years' experience practicing nursing as a licensed Registered Nurse; * A minimum of six (6) years' experience in a supervisory/managerial role in the health insurance industry, a utilization review firm, or another health care claims processing organization involving medical and coding reviews of a variety of medical and surgical claims from a variety of provider types; * Extensive knowledge of state and federal healthcare regulations, policies, coverage guidelines, and reimbursement rules in making clinical determinations as to the medical necessity and appropriateness of services rendered and billed and corresponding payment determinations; * Extensive experience performing medical review and/or utilization/QA reviews; * Extensive knowledge of the Medicaid and/or CHIP program, particularly the coverage, conditions of payment, and state-specific policy requirements for health care coverage and payment; and * Must be a Registered Nurse (RN) in one or more of the 50 states of D.C. * CPC (Certified Professional Coder) required PREFERRED EDUCATION AND EXPERIENCE: -- * Medicaid and/or CHIP medical review experience is preferred. * Demonstrated knowledge of ICD-10CM, CPT-4, and HCPCS Level II coding applications desirable (certification preferred). * For CHIP review, some pediatric nursing experience is preferred. * CPMA (Certified Professional Medical Auditor), CDIP (Certified Documentation Improvement Practitioner), RHIT (Registered Health Information Technician), CCS (Certified Coding Specialist), CCS-P (Certified Coding Specialist - Physician), or CCA (Certified Coding Associate) are preferred. * Inpatient InterQual/Milliman screening or similar product experience. * Optional - We will also need bilingual Medical Reviewers to accommodate the review of Spanish medical records. -- Category: Program / Project Management Confidential

Keywords: NCI Information Systems, Inc., Nashville , Medical Review Subject Matter Expert with Security Clearance, Healthcare , Nashville, Tennessee

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Healthcare Jobs


Physician / Psychiatry / Tennessee / Permanent / PRN - Weekend Psychia
Description: Weekend Psychiatrists Needed at Prestigious Behavioral Health Facility, Nashville, TN Will join two other Board Certified Psychiatrists on weekends and holidays Primary focus will be Inpatient services (more...)
Company: HCA Physician Recruitment
Location: Nashville
Posted on: 12/10/2018

Permanent Urgent Care Physician in Nashville, Tennessee
Description: Urgent Care physician employment in Tennessee : Treat your patients - on your schedule. Leave the back-office administration and insurance to us. Earn a competitive salary. Then go home and enjoy your (more...)
Company: HCA CareNow
Location: Nashville
Posted on: 12/10/2018

Inpatient Rehabilitation - Rehab Nurse - (RN)
Description: Standard br br Qualifications: br br br UP TO 10,000 IN SIGN ON BONUS OFFERED TO QUALIFYING CANDIDATES br br br br br Skyline Medical Center - Nashville, TN br br br br br (more...)
Company: HCA.
Location: Nashville
Posted on: 12/10/2018


Psychiatric Nurse - Travel - (Psych RN)
Description: Job Description Requirements br Psychiatric Nurse - Psych RN br StartDate: ASAP Available Shifts: 12 N Pay Rate: 1116.00 - 1231.00 br br This outstanding Psych unit, based in exciting Nashville (more...)
Company: Onward HealthCare
Location: Nashville
Posted on: 12/10/2018

Registered Nurse (RN) Critical Care Unit (Weekends)
Description: TriStar Skyline Medical Center is Tennessee's first comprehensive stroke center and a national leader in neuroscience. The facility is equipped with 233 beds
Company: Skyline Medical Center HCA Healthcare
Location: Nashville
Posted on: 12/10/2018

Women's Children's PACU Nurse PRN
Description: TriStar Centennial Medical Center - Nashville, TN Registered Nurse RN - Womens Childrens PACU - PRN Our 657 bed hospital is both nationally and locally recognized, including being named as one of (more...)
Company: Centennial Medical Center HCA Healthcare
Location: Nashville
Posted on: 12/10/2018

Permanent Endocrinology Physician in Nashville, Tennessee
Description: Endocrinology physician employment in Tennessee : Nashville, Tennessee Area - Seeking EndocrinologistWalk into an established endocrinology practiceEmployee
Company: Enterprise Medical Recruiting
Location: Nashville
Posted on: 12/10/2018

Progressive Care Cardiac Nurse
Description: TriStar Centennial Medical Center - Nashville, TN 10,000 Sign-On Bonus - 1 yr exp required - HCA employees not eligible Registered Nurse RN - 5 Tower - Cardiac Progressive Care Full Time Nights Our (more...)
Company: Centennial Medical Center HCA Healthcare
Location: Nashville
Posted on: 12/10/2018

Physician / Cardiology - Interventional / Tennessee / Permanent / Interventional Cardiologist Job
Description: Seeking BE/BC Interventional Cardiologist to join our team at Centennial Heart at Skyline. Centennial Heart at Skyline serves the North Nashville communities with our experienced team of cardiovascular (more...)
Company: HCA Physician Recruitment
Location: Nashville
Posted on: 12/10/2018

Nurse Technician PRN
Description: TriStar Skyline Medical Center - Nashville, TN Skyline Medical Center is part of the Tristar family of hospitals: TriStar Skyline Medical Center is Tennessee's first comprehensive stroke center and a (more...)
Company: Skyline Medical Center HCA Healthcare
Location: Nashville
Posted on: 12/10/2018

Log In or Create An Account

Get the latest Tennessee jobs by following @recnetTN on Twitter!

Nashville RSS job feeds