Medical Review Manager – Program Integrity, RN, BSN, MSN required

This is a fully remote position, open to applicants in Arizona, +24 more states.

📋 Description

• Act as the main liaison with CMS regarding Program Integrity operations, which includes status updates, project initiation within the specified timeframe (10 business days), issue escalation, and submission of Initial and Final Project Reports as per SOW requirements; inform CMS within 24 hours before engaging external stakeholders when a Joint Operating Agreement is not in place.

• Oversee and manage the quality assurance and inter-rater reliability process for all Program Integrity medical record reviews, which encompasses the creation of QA protocols, peer review evaluations, and corrective action measures; aim to maintain an accuracy score of 95% or higher on a monthly basis.

• Guide clinical reviewers in pinpointing potential FWA indicators in medical records, such as falsified documentation, altered records, billing pattern irregularities, medically unnecessary services, and signs of patient harm; ensure that review findings are documented in alignment with CMS and FIG standards.

• Directly supervise and lead the clinical review team (RN, LPN, coder, and support staff), which includes responsibilities for hiring, onboarding, performance management, workload allocation, and continuous training.

• Examine Medicare claims data and medical record documentation to uncover FWA trends, billing discrepancies, provider-specific patterns, and program vulnerabilities; formulate lead recommendations and supporting data for submission to CMS for potential additional review projects or referrals.

• Keep updated on Medicare coverage regulations, CMS Program Integrity Manual (IOM 100-8), Unified Case Management (UCM) system procedures, UPIC coordination protocols, and relevant law enforcement referral standards that govern fraud-focused medical review activities.

• Lead the Program Integrity medical review workstream, coordinating with UPICs, law enforcement entities, state agencies, and other external stakeholders as directed by CMS; ensure compliance with SOW requirements and FIG protocols in all referrals, overpayment recoupments, and fieldwork activities.

⛳️ Requirements

• Active Registered Nurse (RN) license in a State, District of Columbia, the Commonwealth of Puerto Rico, or a U.S. territory.

• Licensure must remain valid throughout the duration of employment.

• At least 5 years of clinical experience in an acute care hospital, skilled nursing facility (SNF), and/or an office or clinic-based medical practice.

• Minimum of 5 years of prior medical review experience, including at least 3 years in a management role.

• Comprehensive understanding of the Medicare program, specifically regarding coverage and payment regulations, the medical review process, and CMS program integrity frameworks.

• At least 2 years of experience in fraud-focused medical review activities, including FWA case identification, documentation standards for fraud referrals, and collaboration with CMS program integrity staff and/or law enforcement.

• A Master’s degree from an accredited institution in nursing or a related field; or a Bachelor’s degree in nursing from an accredited institution combined with the relevant experience specified above.

🏝️ Benefits

• Reasonable accommodations can be made to assist individuals with disabilities in fulfilling the essential functions of the role.

• Commence is an equal opportunity employer. All personnel processes are based on merit and are implemented without discrimination based on race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status, or any other characteristic protected by applicable law.

• If you need reasonable accommodation to participate in the application process due to a disability, please reach out to Human Resources at (757) 306-4920 or hr@commence.ai.