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

About the role

The Medical Review Manager, Program Integrity is the senior clinical operations leader for the Fraud Investigations Group support workstream. This role oversees all CMS directed Program Integrity medical reviews, ensuring accuracy and compliance with CMS and FIG standards.

Responsibilities

• Own and administer the quality assurance and inter-rater reliability process for all Program Integrity 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 pattern anomalies, medically unnecessary services, and evidence of patient harm; ensure review findings are documented consistent with CMS and FIG standards.
• Serve as the primary point of contact with CMS on Program Integrity operations, including status reporting, project initiation within required timelines (10 business days), issue escalation, and delivery of Initial and Final Project Reports per SOW requirements; notify CMS within 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, coder, and support staff), including hiring, onboarding, performance management, workload distribution, and ongoing training.
• Cook directly with the Contractor Medical Director (CMD) on complex 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; develop lead recommendations and supporting data for submission to CMS for consideration of additional review projects or referrals.
• Maintain current working knowledge of Medicare coverage rules, CMS Program Integrity Manual (IOM 100-8), Unified Case Management (UCM) system procedures, UPIC coordination protocols, and applicable law enforcement referral standards governing fraud-focused medical review activities.
• Lead the Program Integrity medical review workstream, including coordination with UPICs, law enforcement agencies, state agencies, and other external stakeholders as directed by CMS; ensure all 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 integrity 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 integrity personnel and/or law enforcement.
• 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 outlined above.
• This position is fully dedicated to the Program Integrity workstream. The named Medical Review Manager is expected to personally perform the duties of the position and may not have time split across other program workstreams.

Preferred Qualifications

• Prior Medical Review Manager or program integrity 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 Unified Case Management (UCM) system and the program integrity referral process.

Work Environment/Physical Demands

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.

Benefits

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.

Pay

Competitive salary based on experience and qualifications.

Schedule

Full-time position, Monday through Friday, 8:00 AM - 5:00 PM. Remote work is available for qualified candidates.