Medical Review Manager – CMS Medicare (RVC)

Position Overview

The Medical Review (MR) Manager is responsible for overseeing all medical review activities and quality assurance functions for the CMS Review and Validation Contractor (RVC) program. This role ensures accurate application of Medicare policy, directs daily workflow for medical review staff, and supports the validation of Recovery Audit Contractor (RAC) determinations. The MR Manager must be available Monday–Friday, 8:00 AM to 4:30 PM ET.

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Key Responsibilities

• Manage and oversee medical review operations, including accuracy reviews, disputes, RAC topic evaluations, and special studies.

• Lead and supervise medical review staff to ensure proper application of Medicare policies and procedures.

• Provide clinical expertise and guidance for complex or questionable claim review situations.

• Conduct quality assurance (QA) audits to verify compliance with contract and regulatory requirements.

• Brief, train, and educate review personnel on policy interpretation and validation processes.

• Stay current on medical practice, technology changes, billing trends, and potential areas of improper payments.

• Ensure medical review activities align with CMS FFS Recovery Audit Program requirements.

• Serve as the clinical resource for Medicare coverage, documentation, coding, and regulatory requirements.

• Maintain timely communication with CMS and internal leadership as required.

• Ensure that all duties requiring clinical expertise are performed directly by the MR Manager; non-medical staff may not substitute.

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Required Qualifications

• Minimum of 5 years of medical review experience.

• Minimum of 3 years of experience as a Medical Review Manager, including QA oversight.

• Extensive knowledge of the Medicare program, including coverage, payment, billing, and policy requirements.

• Working knowledge of the CMS Fee-for-Service (FFS) Recovery Audit Program.

• Strong analytical and decision-making skills with demonstrated clinical judgment.

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Education and Licensure

• Registered Nurse (RN), currently licensed in the United States or U.S. Territory (license verified annually).

• Bachelor’s degree in Nursing (BSN) required.

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Core Competencies

• Medical review expertise

• Clinical judgment and decision-making

• Medicare coverage and policy knowledge

• Quality assurance and audit experience

• Leadership and staff management

• Policy interpretation and training

• Strong written and verbal communication

• Attention to detail and accuracy

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Work Schedule

• Monday through Friday

• 8:00 AM to 4:30 PM ET

• Availability required during these hours for CMS and operational needs