Senior Medical Review & Program Integrity Lead

Commence; Virginia Beach (VA); Hybride; USD 140 000 - 160 000; Plein temps

Résumé du poste

Commence, headquartered in Virginia Beach, VA, is seeking a Medical Review Manager to lead the Program Integrity workstream for CMS fraud investigations. The role focuses on supervising clinical reviewers, ensuring QA, and coordinating with CMS, CMD, UPICs and law enforcement to protect the Medicare Trust Fund.

The ideal candidate is an RN with 5+ years of clinical and medical review experience, including 3+ years in management, and a strong working knowledge of CMS program integrity rules and

Qualifications

• Active RN licensure in a US state or territory.
• Minimum 5 years clinical experience in acute care, SNF, or clinic.
• Minimum 5 years of medical review experience, with at least 3 years in management.
• Extensive knowledge of Medicare rules, CMS program integrity frameworks.
• Master’s degree in nursing or equivalent combination of degree and experience.

Responsabilités

• Oversee QA and inter-rater reliability for medical record reviews; maintain 95% accuracy.
• Direct clinical reviewers to identify FWA indicators in records and ensure CMS/FIG standards.
• Serve as CMS liaison; manage timelines, escalation, and report delivery.
• Supervise clinical review team; handle hiring, onboarding, and performance management.
• Coordinate with CMD on complex determinations and field work readiness.
• Analyze Medicare data to identify FWA patterns and inform CMS referrals.
• Maintain knowledge of CMS manuals, UCM processes, UPIC protocols, and law enforcement referrals.
• Lead the workstream; coordinate with UPICs, law enforcement, and state agencies as directed.

Connaissances

RN licensure

clinical experience

medical review experience

management experience

Medicare program knowledge

dedication to program integrity

Formation

Master’s degree in nursing

Bachelor’s degree in nursing + experience

Description du poste

Commence, headquartered in Virginia Beach, VA, is seeking a Medical Review Manager to lead the Program Integrity workstream for CMS fraud investigations. The role focuses on supervising clinical reviewers, ensuring QA, and coordinating with CMS, CMD, UPICs and law enforcement to protect the Medicare Trust Fund.

The ideal candidate is an RN with 5+ years of clinical and medical review experience, including 3+ years in management, and a strong working knowledge of CMS program integrity rules and