Medical Review Manager - Program Integrity (Healthcare)

TL;DR

Medical Review Manager (Healthcare/CMS): Overseeing CMS directed Program Integrity medical reviews to identify fraud, waste, and abuse within Medicare records with an accent on clinical operations and quality assurance. Focus on managing clinical review teams, identifying FWA patterns, and coordinating with CMS and law enforcement agencies.

Location: Remote (Must be based in one of the following US 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)

Company

A data-centric healthcare transformation company focusing on improving health outcomes through data-driven solutions and clinical expertise.

What you will do

• Manage the clinical review team (RNs, LPNs, coders) and oversee nationwide Medicare medical record reviews.
• Identify fraud, waste, and abuse (FWA) indicators in medical records and document findings according to CMS standards.
• Own the quality assurance and inter-rater reliability processes, maintaining a 95%+ accuracy score.
• Act as the primary point of contact for CMS on Program Integrity operations and reporting.
• Analyze claims data to identify provider-specific trends and program vulnerabilities.
• Coordinate with the Contractor Medical Director and external law enforcement or state agencies.

Requirements

• Active Registered Nurse (RN) licensure in a US state or territory.
• Minimum 5 years of clinical experience in acute care, SNF, or clinic settings.
• Minimum 5 years of medical review experience, including at least 3 years in management.
• Deep knowledge of Medicare coverage rules and CMS program integrity frameworks (2+ years in fraud-focused review).
• Bachelor’s (BSN) or Master’s (MSN) degree in nursing from an accredited institution.
• Must be based in one of the specified US states for remote work.

Nice to have

• Prior experience as a Medical Review Manager on a CMS fraud-focused contract.
• Experience managing large clinical teams in a high-volume federal healthcare environment.
• Familiarity with the CMS Unified Case Management (UCM) system and coordination with OIG, DOJ, or UPICs.

Culture & Benefits

• Remote work flexibility for candidates in approved states.
• Purpose-driven culture focused on elevating health outcomes.
• Environment characterized by straightforward communication and clinical expertise.
• Equal employment opportunity employer.