Medical Policy Review Nurse

Type of

Requisition :
Regular Clearance Level Must Currently Possess:
None Clearance Level Must Be Able to Obtain:
None Public Trust/Other

Required:

MBI (T2) Job Family:
Functional Experts

Job Qualifications:

Skills:

Clinical Documentation, Documentation Review, Medical Billing and Coding, Medical Coding, Medical Documentation

Certifications:

None

Experience:

5 + years of related experience US Citizenship

Required:

No

Job Description:

The World Trade Center Health Program is a limited federal health program administered by the National Institute for Occupational Safety and Health (NIOSH), part of the Centers for Disease Control and Prevention (CDC) in the U.S. Department of Health and Human Services (HHS). The Program provides no-cost medical monitoring and treatment for certified WTC‑related health conditions to those directly affected by the 9/11 attacks in New York, the Pentagon, and in Shanksville, Pennsylvania.

The Medical Policy Review Nurse will contribute to the strategic direction of the business and support impactful mission outcomes as a 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 (WTCHP).

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.

• 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.

• 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
• 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;