Medicare Program Integrity Lead — Medical Review

DOMA Technologies

Maryland

On-site

USD 130,000 - 170,000

Full time

14 days+

Application generator

Stand out for this role — generate a tailored resume and cover letter in about a minute.

Get past ATS filters

Job summary

Commence is seeking a Medical Review Manager to lead the Program Integrity medical reviews nationwide. You will supervise a clinical review team of RNs, LPNs, coders and support staff, ensuring accuracy, thorough documentation, and timely CMS reporting.

Ideal candidates possess deep Medicare knowledge, fraud-focused review experience and a master’s or bachelor’s in nursing. This fully remote/office role collaborates with CMS and law enforcement partners under strict confidentiality.

Qualifications

Active RN licensure in a US state or territory and in good standing.
Minimum 5 years in acute care or equivalent clinical setting.
Minimum 5 years in medical review with at least 3 years in management.
2+ years working with fraud-focused medical review and CMS program integrity.

Responsibilities

Oversee QA and inter-rater reliability for medical record reviews with 95%+ accuracy.
Direct clinical reviewers to identify FWA indicators in records and ensure CMS/FWA documentation standards.
Act as primary CMS liaison for Program Integrity operations and reporting.
Supervise and manage RN, LPN, coder and support staff, including hiring and training.
Coordinate with the CMD on complex determinations and external investigations.
Analyze claims data to identify FWA patterns and support CMS referral decisions.
Maintain current knowledge of Medicare rules, CMS IOM 100-8, and UPIC procedures.
Lead the workstream and ensure compliance with SOW and FIG protocols.