LivantaLLC

General

• Arbitrating/deciding payment disputes
• Analyzing documentation and managing case files
• Reviewing dispute-relevant information and requesting additional information as needed
• Remaining neutral and writing concise determinations under deadlines
• Collaborating with technical and legal professionals for appropriate decisions
• Researching jurisdictional and substantive issues

Arbitrator

Physician Reviewer

• Conduct independent, remote case reviews evaluating medical necessity, appropriateness, or quality of care.
• Provide evidence-based assessments and written determinations following established clinical guidelines and review criteria.
• Support case types including Utilization review, Appeals and hearings, Quality of care and standard of care concerns.
• Uphold the highest standard of clinical integrity, neutrality, and objectivity.

Physician Peer Reviewer – actively practicing

Therapist

• Conduct independent, remote case reviews evaluating medical necessity, appropriateness, or quality of care
• Provide evidence-based assessments and written determinations following established clinical guidelines and review criteria
• Support case types including: Utilization review, Appeals and hearings, Quality of care and standard of care concerns
• Uphold the highest standard of clinical integrity, neutrality, and objectivity

Physical Therapist, Interventional Cardiologist

Program Manager

• 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.
• 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.
• Directly supervise and manage the clinical review team (RN, LPN, coder, and support staff), including hiring, onboarding, performance management, workload distribution, and ongoing training.
• 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.

Arbitrator

Physician Peer Reviewer – actively practicing

Physical Therapist, Interventional Cardiologist

Medical Review Manager – Program Integrity, RN, BSN, MSN required