Medical Review Manager – CMS Medicare
Simsy Ventures
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Manage and oversee medical review operations, including accuracy reviews, disputes, RAC topic evaluations, and special studies.
- Lead and supervise medical review staff to ensure proper application of Medicare policies and procedures.
- Provide clinical expertise and guidance for complex or questionable claim review situations.
- Conduct quality assurance (QA) audits to verify compliance with contract and regulatory requirements.
- Brief, train, and educate review personnel on policy interpretation and validation processes.
- Stay current on medical practice, technology changes, billing trends, and potential areas of improper payments.
- Ensure medical review activities align with CMS FFS Recovery Audit Program requirements.
- Serve as the clinical resource for Medicare coverage, documentation, coding, and regulatory requirements.
- Maintain timely communication with CMS and internal leadership as required.
- Ensure that all duties requiring clinical expertise are performed directly by the MR Manager; non-medical staff may not substitute.
Requirements
- Minimum of 5 years of medical review experience.
- Minimum of 3 years of experience as a Medical Review Manager, including QA oversight.
- Extensive knowledge of the Medicare program, including coverage, payment, billing, and policy requirements.
- Working knowledge of the CMS Fee-for-Service (FFS) Recovery Audit Program.
- Strong analytical and decision-making skills with demonstrated clinical judgment.
Benefits
- Health insurance
- Paid time off
- Flexible work arrangements
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
medical review operationsaccuracy reviewsdisputes managementRAC topic evaluationsquality assurance auditsMedicare policiesbilling trendsclinical expertisepolicy interpretationregulatory compliance
Soft skills
leadershipsupervisioncommunicationanalytical skillsdecision-makingclinical judgmenttrainingeducation