Medical Review Manager – Program Integrity, RN, BSN, MSN required

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⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Program Manager

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LivantaLLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2004

⚕️ Healthcare Insurance

📚 Education

Healthcare Insurance • Education • Data Management

Livanta LLC is a technology-enabled organization dedicated to advancing healthcare quality through innovation. It specializes in providing services to patients, caregivers, healthcare providers, and payers, focusing on improving health outcomes, navigating healthcare systems, and ensuring payment accuracy. Livanta is recognized as the largest Medicare Quality Improvement Organization and offers a range of services including quality oversight, auditing, advocacy, and data analytics to enhance patient care and safety while managing healthcare costs effectively.

📋 Description

• Serve as the primary point of contact with CMS on Program Integrity operations, including status reporting, project initiation within required timelines (10 business days), issue escalation, and delivery of Initial and Final Project Reports per SOW requirements; notify CMS within 24 hours prior to engaging external stakeholders in the absence of a Joint Operating Agreement. • Own and administer the quality assurance and inter-rater reliability process for all Program Integrity medical record reviews, including development of QA protocols, peer review assessments, and corrective action procedures; maintain a 95% or greater accuracy score each month. • Direct clinical reviewers to identify potential FWA indicators in medical records, including falsified documentation, altered records, billing pattern anomalies, medically unnecessary services, and evidence of patient harm; ensure review findings are documented consistent with CMS and FIG standards. • Directly supervise and manage the clinical review team (RN, LPN, coder, and support staff), including hiring, onboarding, performance management, workload distribution, and ongoing training. • Analyze Medicare claims data and medical record documentation to identify FWA patterns, billing anomalies, provider-specific trends, and program vulnerabilities; develop lead recommendations and supporting data for submission to CMS for consideration of additional review projects or referrals. • Maintain current working knowledge of Medicare coverage rules, CMS Program Integrity Manual (IOM 100-8), Unified Case Management (UCM) system procedures, UPIC coordination protocols, and applicable law enforcement referral standards governing fraud-focused medical review activities. • Lead the Program Integrity medical review workstream, including coordination with UPICs, law enforcement agencies, state agencies, and other external stakeholders as directed by CMS; ensure all referrals, overpayment recoupments, and field work are executed in compliance with SOW requirements and FIG protocols.

🎯 Requirements

• Active Registered Nurse (RN) licensure in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States. • Licensure must remain in good standing throughout employment. • Minimum 5 years of clinical experience in an acute care hospital, skilled nursing facility (SNF), and/or an office/clinic-based medical practice • Minimum of 5 years of previous medical review experience with at least 3 years of management experience. • Extensive knowledge of the Medicare program, particularly coverage and payment rules, the medical review process, and CMS program integrity frameworks; • Minimum 2 years of experience working with fraud-focused medical review activities, including FWA case identification, documentation standards for fraud referrals, and coordination with CMS program integrity personnel and/or law enforcement. • Master’s degree from an accredited institution in nursing or a related field; or a Bachelor’s degree in nursing from an accredited institution combined with the relevant experience outlined above.

🏖️ Benefits

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. • Commence is an equal employment opportunity for employer. All personnel processes are merit-based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law. • If you require reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or [email protected].