Simsy Ventures

Medical Reviewer

• Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines
• Assessing medical necessity, appropriateness, and reimbursement eligibility while documenting decisions
• Reviewing medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Educating internal and external teams on medical review processes, coverage determinations, and coding requirements
• Supporting quality control activities to meet corporate and team objectives
• Providing guidance to LPN team members and supporting non-clinical staff through training and discussions
• Assisting with special projects and additional responsibilities as assigned

Home Health RN – Medical Claims Reviewer

Project Manager

• Serve as the primary liaison to the Government on all contract issues and policy matters, coordinating with the CMS Contracting Officer (CO) and Contracting Officer’s Representative (COR).
• Lead the post-award Kick-Off Meeting and orientation briefing within seven (7) business days of award, addressing management approach, project work plan, staffing, communications, risk management, and configuration management.
• Develop, maintain, and execute the Project Management Plan and Integrated Master Schedule (IMS), revising the work plan no more frequently than monthly as project conditions evolve.
• Manage project staff and any subcontractors to meet timelines established for both standard and expedited review of Eligibility Determinations and Payment Determinations.
• Ensure timely delivery of high-quality deliverables, including the Audit Strategy, Audit Roadmap, individual audit reports, the Preliminary and Final Annual Audit Reports, and the Operational Readiness and Transition Report.
• Advise CMS in a timely manner of any difficulties arising from contract administration, including sudden increases in inquiry or appeal volume and the team’s ability to absorb workload challenges; manage project costs.
• Provide quality assurance on all draft audit reports to ensure sufficient rationale is documented for every audit decision.
• Lead recruiting, retention, onboarding, and replacement of qualified personnel; scale resources in response to evolving audit volumes and program needs.
• Oversee subcontractor performance and cost controls, ensuring that any use of subcontractors and consultants is selective, strategic, and does not increase project cost.
• Own the contractor’s Quality Control Plan and continuous improvement processes; use performance data to refine processes during Phase 1 and support the transition to Phase 2.
• Safeguard sensitive healthcare information and ensure all work complies with the No Surprises Act, the Federal IDR regulations at 45 CFR 149.510, applicable HHSAR clauses, and all contract security and privacy requirements.

Project Manager, HHS/CMS

Project Manager/Director – CMS, IDRE Audit

Auditor

• Ensure audits are performed in a consistent, impartial, and objective manner across all certified IDR entities.
• Supervise project audit teams, including assignment of work, mentoring, and review of junior auditors’ output.
• Manage and execute completion of assigned tasks within established timelines for standard and expedited audits.
• Provide quality control over audit workpapers, evidence, findings, and recommendations to ensure each audit is well-documented and defensible.
• Review the project team’s audit work, including documentation supporting eligibility and payment determination findings, and the rationale documented in draft audit reports.
• Provide technical assistance to CMS and project staff on audit methodology, including statistically representative sampling design, treatment of single vs. batched disputes, handling of reopened determinations, and assessment of clerical, procedural, or jurisdictional errors.
• Review audit reports and other deliverables and interact with the client on program and technical issues, including the Audit Strategy, individual audit reports, and the Preliminary and Final Annual Audit Reports.
• Apply knowledge of Generally Accepted Accounting Principles (GAAP), Government Auditing Standards (GAS), and applicable Federal regulations — including guidelines, standards, and concepts — and other relevant industry practices to each engagement.
• Assess certified IDR entity compliance with eligibility determination requirements (including batching, State All-Payer Model Agreements, and specified State law applicability), payment determination procedures, recordkeeping, and reporting timeframes.
• Identify recurring issues, emerging trends, and “red flags” for escalation; support calculation of financial impact (e.g., collected but unremitted administrative fees) where applicable.
• Safeguard sensitive healthcare information and ensure audit execution complies with the No Surprises Act, 45 CFR 149.510, and all contract security and privacy requirements.

Lead Auditor – IDR Entity Audit

Director

• Support CMMC implementation efforts
• Conduct gap assessments against CMMC/NIST SP 800-171 requirements
• Assist with the development and updates to the System Security Plan (SSP) and POA&M
• Implement and document security controls, policies, and procedures
• Coordinate with internal stakeholders to ensure compliance across systems and processes
• Support audit readiness and evidence collection
• Secure IT infrastructure (IAM, endpoint security, networks, cloud)
• Provide guidance on best practices for federal compliance environments
• Assist with ongoing monitoring and maintenance post-certification

Home Health RN – Medical Claims Reviewer

Project Manager, HHS/CMS

Project Manager/Director – CMS, IDRE Audit

Lead Auditor – IDR Entity Audit

Director of IT and Technology Solutions