Medical Policy Review Nurse

Medical Policy Review Nurse

The Medical Policy Review Nurse will contribute to the strategic direction of the business and support impactful mission outcomes as an Medical Policy Review Nurse e, you'll enable the success of one of the most critical federal healthcare missions and ensure accurate, clinically-supported coverage determinations for the World Trade Center Health Program. This position will be impactful to the mission of the World Trade Center Health Program (WTC HP).

You will play a crucial role in bridging clinical judgment and coding accuracy to ensure coverage, authorization requirements, and claims integrity align with clinical documentation, medical policy, coding standards, and federal regulatory requirements.

MEANINGFUL WORK AND PERSONAL IMPACT

Lead the evaluation of CPT, HCPCS Level II, ICD-10-CM/PCS, MS-DRG, revenue, and other codes against clinical evidence, benefit language, medical policy, and regulatory guidance to support coverage determinations. Collaborate with Medical Directors, Utilization Management staff, coding/compliance teams, product teams, and policy analysts to ensure coding and coverage logic remain clinically appropriate, operationally feasible, and compliant. Drive high-quality clinical and coding outcomes by performing code validations, identifying incorrect or inconsistent usage, recommending prior authorization requirements, supporting audits, and advising on emerging procedures, technologies, and regulatory changes.

Utilize coding guidelines, clinical literature, CMS NCD/LCDs, medical necessity concepts, and utilization management criteria to develop evidence-based recommendations for coverage, authorization, and coding treatment.

WHAT YOU'LL NEED TO SUCCEED

Bring your initiative and clinical/coding expertise to GDIT. The Medical Policy Review Nurse must have:

• Education:
  
  Associate degree in Nursing required; bachelor's degree preferred
• Experience:
  
  Registered Nurse with demonstrated experience in medical coding, medical policy, utilization management, claims, reimbursement, or clinical documentation review
• Technical skills:
• CPT
• HCPCS Level II
• ICD-10-CM
• ICD-10-PCS
• Revenue codes
• Modifiers
• Place of Service codes
• NCCI edits
• Medical necessity standards
• Prior authorization processes
• Benefit/coverage concepts
• Certifications:
  
  CPC, CCS, CCA, CRC, or equivalent preferred
• Security clearance level: MB(T2)
• Role requirements:
  
  Ability to conduct detailed clinical coding reviews, evaluate medical documentation, research complex clinical/coding subjects, interpret medical policy, and collaborate across clinical, operational, and coding teams;