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Medical Review Manager Jobs (NOW HIRING)

MedWatch

Medical Review Coordinator / LPN

Lake Mary, FL · Remote

At the direction of the Medical Review Specialist, discuss potential case management referrals with the case management supervisor and refer as directed to the claims office. * Obtain discharge dates ...

Otsuka Pharmaceutical Co., Ltd

Supports vendor oversight activities for the Medical Review function, including performance monitoring, issue management, and ensuring compliance with company and regulatory expectations.* Monitors ...

Managed Medical Review Organization

About MMRO Managed Medical Review Organization (MMRO) is an established, URAC-accredited Independent Review Organization (IRO) that provides objective, evidence-based medical peer reviews nationwide.

Ampcus

Clinical Medical Review Nurse

Baltimore, MD · On-site

Clinical Medical Review Nurse. Location: Baltimore, MD. Purpose: * The Clinical Medical Review ... Experience: * 3 years acute clinical experience, previous case management, discharge planning or ...

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Medical Review Manager information

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How much do medical review manager jobs pay per hour?

As of Sep 9, 2026, the average hourly pay for medical review manager in the United States is $44.26, according to ZipRecruiter salary data. Most workers in this role earn between $28.85 and $57.69 per hour, depending on experience, location, and employer.

What does a medical review manager do?

A Medical Review Manager oversees the evaluation of medical information, typically within clinical trials or insurance contexts, to ensure compliance with regulations and company standards. They lead teams that review medical documents, patient records, or clinical data to assess safety, efficacy, and adherence to protocols. Additionally, they collaborate with medical professionals, regulatory bodies, and other departments to resolve issues and improve review processes. Their role is crucial in maintaining the quality and accuracy of medical assessments and supporting organizational goals.

What are the key skills and qualifications needed to thrive as a medical review manager?

To thrive as a Medical Review Manager, you need a solid background in healthcare or life sciences, experience in clinical or medical review, and often a relevant degree such as RN, MD, or PharmD. Familiarity with regulatory guidelines, medical coding systems, and tools like MedDRA or clinical trial management software is typically required. Strong analytical thinking, attention to detail, and effective communication are essential soft skills for success in this role. These competencies ensure accurate medical evaluations, regulatory compliance, and seamless collaboration with cross-functional teams.

What are the typical challenges faced by a medical review manager when collaborating with cross-functional teams?

Medical Review Managers often collaborate with clinical, regulatory, and safety teams, which can present challenges such as aligning differing priorities and timelines. Effective communication and strong organizational skills are crucial to ensure that all stakeholders are updated and that the review process runs smoothly. Navigating complex regulatory requirements and integrating feedback from multiple departments can also require adaptability and diplomatic problem-solving. Building strong relationships across teams helps streamline workflows and supports successful project outcomes.

What is the difference between Medical Review Manager vs Medical Reviewer?

AspectMedical Review ManagerMedical Reviewer
CertificationsMedical license, possibly additional certifications in clinical reviewMedical license, often with specific clinical review certifications
Work EnvironmentOversees review teams, manages processes, and ensures compliancePerforms clinical reviews, evaluates medical records and claims
Employer & Industry UsageInsurance companies, healthcare organizations, government agenciesInsurance companies, healthcare providers, third-party review organizations

The Medical Review Manager typically supervises review teams and manages review processes, requiring leadership skills and extensive clinical knowledge. In contrast, the Medical Reviewer focuses on conducting detailed medical evaluations and assessments. Both roles require medical licensure and clinical expertise, but the Manager has additional responsibilities in oversight and process management.

How to become a medical review manager?

To become a medical review manager, candidates typically need a medical degree such as a medical doctor (MD) or registered nurse (RN) license, along with experience in healthcare or medical claims review. Strong analytical skills, knowledge of medical coding and documentation, and familiarity with healthcare regulations are essential, and some roles may require certification such as Certified Medical Review Officer (CMRO).
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Medical Review Manager jobs near you

Medicaid Medical Review RN (Medical Reviewer III)

Remote

CoventBridge Group
11 - 50 employees
Learn more about CoventBridge Groupexternal

$78K - $85K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

This job post has expired today. Applications are no longer accepted.

CoventBridge Group rating

6.7

Company rating: 6.7 out of 10

Based on 13 frontline employees who took The Breakroom Quiz

310th of 501 rated business services

Job description

Overview
Medicaid Medical Review RN (Medical Reviewer III) - REMOTE
The Medicaid Medical Review RN (Medical Reviewer III) will primarily be responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. In addition, this position applies Medicare and Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage.
In assuming this position, you will be a critical contributor to meeting CoventBridge Integrity System's objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.
This position will report directly to the Medical Review Supervisor and will work in our Grove City, OH office. If not local, remotely from a home office.
Responsibilities/ Requirements
Responsibilities:
  • Reviews information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare or Medicaid payment policies
  • Utilizes extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare/Medicaid and Contractor guidelines for coverage determinations
  • Coordinates and compiles the written Investigative Summary Report to the PI Investigator upon completion of the records review
  • Incorporates leadership and communication skills to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel
  • Provides training to UPIC staff on medical terminology, reading medical records, and policy interpretation
  • Provides expert witness testimony as required
  • Completes assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy
  • Maintains chain of custody on all documents and follows all confidentiality and security guidelines
  • Performs other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations

Requirements:
  • 2 years minimum experience with a state Medicaid agency or Managed Care Organization focused in Medicaid
  • 2 years minimum of working knowledge of ICD 10-CM/CPT coding experience
  • 4 years minimum experience auditing claims history or provider files to determine if the claim was payable and if any signed of fraud, waste or abuse are noted
  • Knowledge of, and the ability to correctly identify, Medicare and Medicaid coverage guidelines
  • Advance knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/ quality assurance procedures, ICD 10-CM and CPT coding, Medicare coverage guidelines and payment methodologies (i.e., Correct Coding Initiative, DRG's, Prospective Payment Systems and Ambulatory Surgical center), NCPCP and other types of prescription drug claims
  • Ability to read Medicaid claims, both paper and electronic, and a basic knowledge of Medicaid is required
  • Should possess excellent verbal and written communication skills with an ability to write professional summary reports
  • Knowledge of and ability to use Microsoft Word, Excel, and Internet applications
  • Able to efficiently organize and manage workload and assignments
  • Must have and maintain a valid driver' license for the state of residence as on-site audits are part of the role as a nurse reviewer

Educational/Experience Qualifications:
  • Graduate from an accredited school of nursing and have an active license as a Registered Nurse (RN) required
  • Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews

Benefits
  • Medical, Dental, Vision plans
  • Life, LTD and STD paid by the employer
  • 401(k) with company match up to 4%
  • Paid Time Off and company paid holidays
  • Tuition assistance after 1 year of service

The salary range for this role is $78,000 to $85,000 annually. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
At this time, CoventBridge is not considering candidates who require visa sponsorship, currently or in the future, including but not limited to H-1B, H-2B, E-3, TN, O-1, F-1 (OPT/CPT, or J-1 Visa Statuses.)
About Us:
CoventBridge Integrity Systems delivers investigative services, technology, and expertise that help healthcare and government organizations protect critical programs, strengthen oversight, and address fraud, waste, abuse, and operational risk.
CoventBridge Integrity Systems is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintains a drug-free workplace.
CoventBridge Integrity Systems is committed to the full inclusion of all qualified individuals. As part of this commitment, CoventBridge Integrity Systems will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact: Human Resources; 888-932-7364; humanresources@coventbridge.com.

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