Medical Review Manager – CMS Medicare

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Simsy Ventures

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B2B • Startup • Sustainability

Simsy Ventures is a venture builder and institutional co-founder that partners with entrepreneurs, investors, and corporations to create sustainable startups. Their mission focuses on enabling startups to achieve true potential while promoting a positive impact on profits, people, and the planet. With a structured approach, they support startups throughout their lifecycle, from ideation to market validation and growth. By leveraging a repeatable venture studio model, Simsy Ventures aims to uplift economies globally through impactful entrepreneurship.

11 - 50 employees

Founded 2022

🤝 B2B

📋 Description

• 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.

🎯 Requirements

• 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.

🏖️ Benefits

• Health insurance • Paid time off • Flexible work arrangements