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: Administration 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 c ontribute 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. 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 ● 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; ● Must have prior supervisory and/or team management experience ● 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 GDIT IS YOUR PLACE ● Growth: AI-powered career tool that identifies career steps and learning opportunities ● Support: An internal mobility team focused on helping you achieve your career goals ● Rewards: Comprehensive benefits and wellness packages, 401K with company match, competitive pay, and paid time off ● Flexibility: Full-flex work week to own your priorities at work and at home ● Community: Award-winning culture of innovation and a military-friendly workplace OWN YOUR OPPORTUNITY Explore a career at GDIT and you’ll find endless opportunities to grow alongside colleagues who share your passion for advancing clinical accuracy, coding integrity, and mission‑critical healthcare delivery. #GDITFedHealthJobs #WTCJobs The likely salary range for this position is $85,093 - $115,000. This is not, however, a guarantee of compensation or salary. Rather, salary will be set based on experience, geographic location and possibly contractual requirements and could fall outside of this range. Scheduled Weekly Hours: 40 Travel Required: Less than 10% T elecommuting Options: Remote Work Location: Any Location / Remote Additional Work Locations: Total Rewards at GDIT: Our benefits package for all US-based employees includes a variety of medical plan options, some with Health Savings Accounts, dental plan options, a vision plan, and a 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. To encourage work/life balance, GDIT offers employees full flex work weeks where possible and a variety of paid time off plans, including vacation, sick and personal time, holidays, paid parental, military, bereavement and jury duty leave. GDIT typically provides new employees with 15 days of paid leave per calendar year to be used for vacations, personal business, and illness and an additional 10 paid holidays per year. Paid leave and paid holidays are prorated based on the employee’s date of hire. The GDIT Paid Family Leave program provides a total of up to 160 hours of paid leave in a rolling 12 month period for eligible employees. To ensure our employees are able to protect their income, other offerings such as short and long-term disability benefits, life, accidental death and dismemberment, personal accident, critical illness and business travel and accident insurance are provided or available.