Virginia Licensed Medical Review Manager
Job Summary
To lead the Fraud Investigations Group's medical review efforts, the fully remote Virginia Licensed Medical Review Manager will oversee CMS-directed Program Integrity medical reviews, manage a clinical review team, and ensure compliance with fraud identification standards.
Key responsibilities
- Administer quality assurance processes for medical record reviews, maintaining a 95% accuracy score monthly
- Direct clinical reviewers in identifying fraud, waste, and abuse indicators in medical records
- Serve as the primary contact with CMS for Program Integrity operations, including status reporting and project initiation
Required qualifications
- Active Registered Nurse (RN) licensure in good standing
- Minimum 5 years of clinical experience in acute care, skilled nursing, or medical practice
- At least 5 years of medical review experience, with 3 years in a management role
- Extensive knowledge of Medicare program integrity frameworks and fraud-focused medical review activities
- Master's degree in nursing or a related field, or a Bachelor's degree in nursing with relevant experience
Complete Job Description
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