NCI Medical Review RN in Grove City, Ohio

Medical Review RN

Posting Date:


Job Number:



Grove City, OH



Security Clearance Status:

Not Applicable

Security Clearance Type:


US Citizenship Required:


Job Level:

Individual Contributor

Employment Status:

Regular Full-Time



NCI: As the Medical Review RN ( Medical Reviewer III ), you will be primarily responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. You will apply Medicare and Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage. In assuming this position, you will be a critical contributor to meeting NCI 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:

  • Reviews information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies.

  • Utilizes extensive knowledge of medical terminology, ICD-9-CM/10, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare and Contractor guidelines for coverage determinations.

  • Coordinates and compiles the written Investigative Summary Report to the PI Investigator upon completion of the records review.

  • Incorporates leadership and communication skills to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel.

  • Provides training to UPIC staff on medical terminology, reading medical records, and policy interpretation.

  • Provides expert witness testimony as required.

  • Completes assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy.

  • Maintains chain of custody on all documents and follows all confidentiality and security guidelines.


  • At least 4 years utilization/quality assurance review and ICD-9/10-CM/CPT-4 coding experience.

  • At least 4 years'experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines.

  • Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9/10-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required.

  • Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems.

  • Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN). Must have and maintain a valid drivers license for the associate's state of residence. This is required if onsite investigations are requested for employee to participate in.

Preferred Education and Experience:

  • Experience with Home Health & Hospice reviews.

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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.