Medicare Program Integrity Lead — Medical Review

DOMA Technologies; Maryland; Remote; USD 130,000 - 170,000; Full time

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.

Skills

RN licensure

Medicare knowledge

clinical review leadership

FWA experience

CMS programs

Education

Master’s in Nursing

Bachelor’s in Nursing

Tools

CMS UCM system

CMS program integrity frameworks

Job description

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.