Medical Policy Review Nurse

General Dynamics Information Technology•USA VA Home Office (VAHOME), VA

5d•$85,000 - $115,000•Remote

About The Position

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 an Medical Policy Review Nurse at GDIT. Here, 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.

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
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
CPC, CCS, CCA, CRC, or equivalent preferred
MB(T2) security clearance level
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
Prior supervisory and/or team management experience

Nice To Haves

Bachelor's degree

Responsibilities

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.

Benefits

Medical plan options
Health Savings Accounts
Dental plan options
Vision plan
401(k) plan offering the ability to contribute both pre and post-tax dollars up to the IRS annual limits and receive a company match
Full flex work weeks
Variety of paid time off plans, including vacation, sick and personal time, holidays, paid parental, military, bereavement and jury duty leave
15 days of paid leave per calendar year to be used for vacations, personal business, and illness
10 paid holidays per year
Paid Family Leave program provides a total of up to 160 hours of paid leave in a rolling 12 month period for eligible employees
Short and long-term disability benefits
Life insurance
Accidental death and dismemberment insurance
Personal accident insurance
Critical illness insurance
Business travel and accident insurance