Sr. Nurse Reviewer (Medicare)

About the Role

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient processes for 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.

Responsibilities

• Conduct the highest-complexity and escalated clinical medical reviews, including reassigned cases where the original reviewer is no longer available, consistent with SOW continuity requirements for Discussion & Education sessions.
• Serve as a mentor and technical resource for Nurse Reviewers and Certified Coders on complex, mixed clinical/coding claims.
• Lead or contribute to inter-rater reliability and peer-review QA activities supporting the SOW's required 95%+ monthly accuracy standard.
• Contribute to the development and maintenance of medical review training materials and the Quality Control assessment plan.
• Monitor team-level accuracy and quality trends; recommend corrective actions and process improvements to the Medical Review Manager.
• Support vulnerability identification and trend/root-cause analysis for Program Integrity reviews.
• Complete required annual CMS trainings and maintain HIPAA/PHI compliance.

Requirements

• Bachelor's degree in nursing or a related healthcare field.
• Active, unrestricted RN license; compact multistate RN license acceptable.
• 5+ years of clinical experience, including 3+ years of Medicare-related utilization review, medical review, or claims review experience.
• Demonstrated experience providing guidance, mentorship, or lead-level direction to other clinical reviewers (RN/LPN) and/or coding staff.
• Extensive knowledge of Medicare coverage, coding, and payment rules, including NCD/LCD application.
• Strong analytical, written, and verbal communication skills; ability to handle confidential/sensitive information with discretion.

Qualifications

• Prior experience as a senior/lead reviewer or “Medical Reviewer III”-equivalent on a MAC, RAC, QIO, or SMRC-type contract (preferred).
• Experience participating in inter-rater reliability or peer-review quality assurance programs (preferred).
• CPC (or similar) coding certification (preferred).
• Experience supporting case file preparation for Administrative Law Judge (ALJ) hearing participation (preferred).

Work Environment/Physical Demands

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 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.

Commence.AI 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 (757) 306-4920 or hr@commence.ai. Please note that unless you are requesting an accommodation, all applications must be submitted through our online application system.