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With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.

The Medical Review Manager, Program Integrity is the senior clinical operations leader for the Fraud Investigations Group support workstream, responsible for overseeing all CMS directed Program Integrity medical reviews conducted in collaboration with the Fraud Investigations Group (FIG). This individual manages the clinical review team executing nationwide, comprehensive medical record reviews aimed at identifying fraud, waste, and abuse (FWA) and protecting the Medicare Trust Fund. The MRM reports directly to the Project Manager and works in close coordination with the Contractor Medical Director (CMD) on complex clinical findings, FWA pattern identification, and coordination with external law enforcement and program integrity stakeholders. This role requires deep experience in Medicare fraud-focused medical review, knowledge of CMS program integrity frameworks, and the ability to operate within the heightened confidentiality and coordination requirements of FIG-directed work.   

Essential Duties and Responsibilities:

• 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.
• 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.
• Directly supervise and manage the clinical review team (RN, LPN, coder, and support staff), including hiring, onboarding, performance management, workload distribution, and ongoing training. 
• Coordinate with the Contractor Medical Director (CMD) on complex clinical determinations, FWA referral decisions, suspected quality-of-care concerns, and preparation for any field work or on-site investigation support requested by CMS. 
• 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.  

Qualifications:

• Active Registered Nurse (RN) licensure in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States. Licensure must remain in good standing throughout employment.
• Minimum 5 years of clinical experience in an acute care hospital, skilled nursing facility (SNF), and/or an office/clinic-based medical practice
• Minimum of 5 years of previous medical review experience with at least 3 years of management experience. 
• Extensive knowledge of the Medicare program, particularly coverage and payment rules, the medical review process, and CMS program integrity frameworks; minimum 2 years of experience working with fraud-focused   medical review activities, including FWA case identification, documentation standards for fraud referrals, and coordination with CMS program integrity   personnel and/or law enforcement. 
• Master’s degree from an accredited institution in nursing or a related field; or a Bachelor’s degree in nursing from an accredited institution combined with the relevant experience outlined above.
• This position is fully dedicated to the Program Integrity workstream. The named Medical Review Manager is expected to personally perform the duties of the position and may not have time split across other program workstreams.  

Preferred Qualifications:

• Prior Medical Review Manager or program integrity clinical operations experience on a CMS contract with a fraud-focused workstream. 
• Demonstrated experience managing large clinical reviewer teams comprising RN, LPN, and coding staff in a high-volume, deadline-driven federal healthcare contracting environment.
• Experience coordinating with external law enforcement, OIG, DOJ, state agencies, or UPICs in support of fraud investigation activities; familiarity with CMS Unified Case Management (UCM) system and the program integrity referral process. 

 *Commence' headquarters are in Virginia Beach, VA, however we are open to remote candidates in the following 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, and WV* 

Work Environment/Physical Demands 

The work environment and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

This is an office/remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch. 

Commence is an equal employment opportunity for employer. All personnel processes are merit-based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law.  

Commmence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or hr@commence.ai. 

Please note that unless you are requesting an accommodation, all applications must be submitted through our online application system.