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