Medical Review Manager Federal Health (CMS)

At Commence were the start of a new age of data-centric transformation elevating health outcomes and powering better 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 proof 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 Commence cuts straight to better care.

The Medical Review Manager (MRM) is the senior clinical operations leader for a CMS program serving as the operational bridge between the Project Manager and the clinical review team. This individual owns the quality assurance process for all medical record reviews manages inter-reviewer reliability to ensure consistent and defensible clinical decisions across the review team and serves as the primary point of contact with CMS on medical review operations. The MRM reports directly to the Project Manager and works in close coordination with the Contractor Medical Director (CMD) on complex clinical matters escalations and program-wide quality initiatives. This is a high-accountability high-volume role requiring deep Medicare clinical review expertise and proven experience managing multi-disciplinary clinical teams in a federal contracting environment.

Essential Duties and Responsibilities

• Own and administer the quality assurance process for all medical record reviews including development and maintenance of QA protocols audit methodologies and corrective action procedures.
• Manage inter-reviewer reliability implementing calibration activities and decision-consistency checks to ensure that clinical determinations are uniform defensible and aligned with Medicare coverage policy across the entire review team.
• Serve as the primary point of contact with CMS on day-to-day medical review operations including status reporting issue escalation and coordination of review activities against contract deliverable timelines.
• Directly supervise and manage the clinical review team (RN LPN coder and support staff) including hiring onboarding performance management workload distribution and ongoing training.
• Coordinate with the Contractor Medical Director (CMD) on complex clinical determinations escalated cases physician-level reviews and preparation for Discussion and Education (D&E) sessions and Administrative Law Judge (ALJ) hearings.
• Analyze Medicare claims data and medical record documentation to identify review patterns outliers and opportunities for process improvement; report findings to the PM and CMS as required.
• Maintain current working knowledge of Medicare coverage rules National Coverage Determinations (NCDs) Local Coverage Determinations (LCDs) Medicare payment policy and applicable CMS program integrity guidance.
• Support the Program Integrity workstream by overseeing fraud waste and abuse (FWA) medical review activities in accordance with CMS direction and SOW requirements.

Qualifications

• Active Registered Nurse (RN) licensure required. Licensure must remain in good standing throughout employment.
• Minimum 5 years of clinical experience in an acute care hospital skilled nursing facility (SNF) or office/clinic setting.
• Extensive knowledge of Medicare program coverage payment rules and the regulatory framework governing Medicare Part A Part B and DMEPOS.
• Demonstrated experience in the analysis and processing of Medicare claims and the application of clinical review judgment to coverage and payment determinations.
• Advanced degree in Nursing Healthcare Administration or a closely related field lieu of an advanced degree a Bachelors degree plus a minimum of 3 additional years of directly related experience may be substituted.

Preferred Qualifications

• Prior Medical Review Manager or clinical operations lead experience on a CMS medical review contract.
• Demonstrated experience managing large clinical reviewer teams comprising RN LPN and coding staff in a high-volume deadline-driven federal healthcare contracting environment.
• Experience with fraud waste and abuse (FWA) medical review activities including case identification documentation standards and coordination with CMS program integrity personnel.

*Commence 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 perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This is a 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.

Commence is an equal employment opportunity for employer. All 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 origin military and veteran status or any other characteristic protected by applicable law.

is committed to providing equal employment opportunities to all 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 or .

Please note that unless you are requesting an accommodation all applications must be submitted through our online application system.