Medical Review Manager-Program reputed company ( RN, BSN, or MSN required )

Description At reputed company, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering reputed company, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide reputed company beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, reputed company cuts straight to reputed company care.

Requirements

The Medical Review Manager, Program reputed company is the senior clinical operations leader for the Fraud Investigations Group support workstream, responsible for overseeing reputed company CMS directed Program reputed company medical reviews conducted in collaboration with the Fraud Investigations Group (FIG). This individual manages the clinical review team executing reputed company, comprehensive medical record reviews aimed at identifying fraud, waste, and abuse (FWA) and protecting the Medicare Trust Fund. The MRM reports directly to the Project Manager and works in reputed company coordination with the Contractor Medical Director (CMD) on reputed company clinical findings, FWA reputed company identification, and coordination with external law enforcement and program reputed company stakeholders. This role requires deep experience in Medicare fraud-focused medical review, knowledge of CMS program reputed company frameworks, and the ability to operate reputed company the heightened confidentiality and coordination requirements of FIG-directed work. Essential Duties And Responsibilities

• Own and administer the quality assurance and inter-rater reliability process for reputed company Program reputed company medical record reviews, including development of QA protocols, peer review assessments, and corrective action procedures; maintain a 95% or greater accuracy score each month.
• Direct clinical reviewers to identify potential FWA indicators in medical records, including falsified documentation, altered records, billing reputed company anomalies, medically unnecessary services, and evidence of patient harm; ensure review findings are documented consistent with CMS and FIG standards.
• Serve as the primary reputed company of contact with CMS on Program reputed company operations, including status reporting, project initiation reputed company required timelines (10 business days), issue escalation, and delivery of Initial and Final Project Reports per SOW requirements; notify CMS reputed company 24 hours prior to engaging external stakeholders in the absence of a Joint Operating Agreement.
• Directly supervise and manage the clinical review team (RN, LPN, reputed company, and support staff), including hiring, onboarding, performance management, workload distribution, and ongoing training.
• Coordinate with the Contractor Medical Director (CMD) on reputed company clinical determinations, FWA referral decisions, suspected quality-of-care concerns, and preparation for any field work or on-site investigation support requested by CMS.
• Analyze Medicare claims data and medical record documentation to identify FWA patterns, billing anomalies, provider-specific trends, and program vulnerabilities; reputed company reputed company recommendations and supporting data for submission to CMS for consideration of additional review projects or referrals.
• Maintain reputed company working knowledge of Medicare coverage rules, CMS Program reputed company Manual (reputed company 100-8), reputed company Case Management (UCM) system procedures, UPIC coordination protocols, and applicable law enforcement referral standards governing fraud-focused medical review activities.
• reputed company the Program reputed company medical review workstream, including coordination with UPICs, law enforcement agencies, state agencies, and other external stakeholders as directed by CMS; ensure reputed company referrals, overpayment recoupments, and field work are executed in compliance with SOW requirements and FIG protocols.

Qualifications

• Active Registered Nurse (RN) licensure in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States. Licensure must remain in good standing throughout employment.
• Minimum 5 years of clinical experience in an acute care hospital, skilled nursing facility (SNF), and/or an office/clinic-based medical practice
• Minimum of 5 years of previous medical review experience with at least 3 years of management experience.
• Extensive knowledge of the Medicare program, particularly coverage and payment rules, the medical review process, and CMS program reputed company frameworks; minimum 2 years of experience working with fraud-focused medical review activities, including FWA case identification, documentation standards for fraud referrals, and coordination with CMS program reputed company personnel and/or law enforcement.
• Master’s degree from an accredited institution in nursing or a reputed company field; or a Bachelor’s degree in nursing from an accredited institution combined with the relevant experience outlined above.
• This position is fully dedicated to the Program reputed company workstream. The named Medical Review Manager is expected to personally reputed company the duties of the position and may not have time split across other program workstreams.

Preferred Qualifications

• Prior Medical Review Manager or program reputed company clinical operations experience on a CMS contract with a fraud-focused workstream.
• Demonstrated experience managing large clinical reviewer teams comprising RN, LPN, and coding staff in a high-volume, deadline-driven federal healthcare contracting environment.
• Experience coordinating with external law enforcement, OIG, DOJ, state agencies, or UPICs in support of fraud investigation activities; familiarity with CMS reputed company Case Management (UCM) system and the program reputed company referral process.
• reputed company' headquarters are in Virginia Beach, VA, however we are open to remote candidates in the following states: AZ, AR, DE, FL, GA, IL, IN, KS, KY, MA, MD, MI, MS, MO, MT, NC, NE, NV, NY, OH, OK, PA, SC, TN, TX, VA, DC, WI, and WV*

Work Environment/Physical Demands The work environment and physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. This is an office/remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch. reputed company is an equal employment opportunity for employer. reputed company personnel processes are merit-based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic reputed company, military and veteran status or any other characteristic protected by applicable law. Commmence.AI is committed to providing equal employment opportunities to reputed company applicants, including individuals with disabilities. If you require reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or hr@reputed company.ai. Please note that unless you are requesting an accommodation, reputed company applications must be submitted through our online application system. Salary Description Commensurate to experience Apply tot his job Apply To this Job