Medical Review Manager (CMS)

TL;DR

Medical Review Manager (CMS): Leading clinical operations for federal health programs with an accent on quality assurance, inter-reviewer reliability, and CMS contract compliance. Focus on managing multi-disciplinary clinical teams, analyzing Medicare claims data, and ensuring defensible clinical determinations in a high-volume environment.

Location: Remote (Must be based in 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, or WV)

Company

hirify.global is a data-centric healthcare transformation company providing value-based solutions to improve patient health outcomes and operational efficiency.

What you will do

• Own and administer the quality assurance process for all medical record reviews, including audit methodologies and corrective actions.
• Manage inter-reviewer reliability to ensure consistent and defensible clinical decisions aligned with Medicare coverage policy.
• Serve as the primary point of contact with CMS for day-to-day medical review operations and status reporting.
• Supervise and manage the clinical review team, including hiring, onboarding, and performance management.
• Coordinate with the Contractor Medical Director on complex clinical determinations and escalated cases.
• Analyze Medicare claims data to identify review patterns and opportunities for process improvement.

Requirements

• Active Registered Nurse (RN) licensure required.
• Minimum 5 years of clinical experience in an acute care, SNF, or clinic setting.
• Extensive knowledge of Medicare program coverage, payment rules, and regulatory frameworks (Part A, Part B, DMEPOS).
• Advanced degree in Nursing or Healthcare Administration (or Bachelor’s degree with 3+ additional years of relevant experience).
• Must reside in one of the approved 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, or WV.

Nice to have

• Prior experience as a Medical Review Manager on a CMS contract.
• Experience managing large clinical reviewer teams including RN, LPN, and coding staff.
• Background in fraud, waste, and abuse (FWA) medical review activities.

Culture & Benefits

• Purpose-driven culture focused on improving patient care.
• Remote work environment with climate-controlled home office requirements.
• Opportunity to work on high-impact federal healthcare contracts.
• Commitment to equal employment opportunity and merit-based advancement.