Medical Policy Review Nurse

General Dynamics
United States
Workplace: RemoteFull timeUSD 85,000 - 115,000 annuallyFunction: Healthcare (Clinical, Medical, Wellness)Experience: 5+ yearsEducation: associatesSkills: ["Clinical judgment","Attention to detail","Collaboration","Research skills","Compliance mindset"]

Review medical policy and clinical documentation to support accurate, clinically supported coverage determinations for the World Trade Center Health Program. Evaluate CPT, HCPCS Level II, ICD-10-CM/PCS, MS-DRG, revenue codes, and modifiers against clinical evidence, policy, and federal guidance. Collaborate with medical directors, utilization management, coding/compliance teams, and policy analysts to validate codes, recommend prior authorization needs, and ensure compliance and claims integrity.

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FursaFursa
General Dynamics
General Dynamics
2 days ago

Medical Policy Review Nurse

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Source: Company careers pageValidated by: Fursa AI
Last checked: 18 hours agoStatus: Live

Job Summary

Review medical policy and clinical documentation to support accurate, clinically supported coverage determinations for the World Trade Center Health Program. Evaluate CPT, HCPCS Level II, ICD-10-CM/PCS, MS-DRG, revenue codes, and modifiers against clinical evidence, policy, and federal guidance. Collaborate with medical directors, utilization management, coding/compliance teams, and policy analysts to validate codes, recommend prior authorization needs, and ensure compliance and claims integrity.
Location: United States
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)

Key Responsibilities

  • •Evaluate CPT, HCPCS Level II, ICD-10-CM/PCS, MS-DRG, revenue, and other codes against clinical evidence, benefit language, medical policy, and regulatory guidance.
  • •Collaborate with Medical Directors, Utilization Management, coding/compliance teams, product teams, and policy analysts to ensure coding and coverage logic remains clinically appropriate and compliant.
  • •Perform code validations, identify incorrect or inconsistent usage, recommend prior authorization requirements, and support audits.
  • •Develop evidence-based recommendations using coding guidelines, clinical literature, CMS NCD/LCDs, and medical necessity concepts.
  • •Advise on emerging procedures, technologies, and regulatory changes affecting coverage and coding determinations.
Travel: Low travel

Pay and Benefits

Salary: USD 85,000 - 115,000 annually
Perks:Health InsuranceDentalVision401kPaid Leave

Key Requirements

  • •Associate degree in Nursing required; bachelor’s degree preferred.
  • •Registered Nurse with demonstrated experience in medical coding, medical policy, utilization management, claims, reimbursement, or clinical documentation review.
  • •Ability to conduct detailed clinical coding reviews, evaluate medical documentation, and research complex clinical/coding topics.
  • •Interpret medical policy and apply medical necessity concepts to support coverage, authorization, and coding treatment.
  • •Prior supervisory and/or team management experience is required.
Experience:5+ years
Education:Associate's in Nursing
Skills:Clinical judgmentAttention to detailCollaborationResearch skillsCompliance mindset
Certifications:CPCCCSCCACRC
Tech Stack:Clinical DocumentationMedical Billing and CodingMedical CodingCPTHCPCS Level IIICD-10-CMICD-10-PCSRevenue codesModifiersPlace of Service codesNCCI editsMedical necessity standardsPrior authorization processesBenefit/coverage concepts

Eligibility

Work Authorization:Sponsorship available.
Security Clearance:MBI (T2)

Company Brief

General Dynamics
Provides IT, systems engineering, cybersecurity, cloud, and mission support services to U.S. federal civilian and defense agencies, delivering large-scale technology solutions and managed services for national security and government operations.
Industry: Defense Technology
Company Size: Enterprise (1,001+ employees)
Growth: Established Company
Headquarters: Tysons / Fairfax, United States
WebsiteLinkedIn