Remote Claim Reviewer Jobs in Virginia (NOW HIRING)

Description

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care.

With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.

Requirements

The Program Director as the senior operational leader for a CMS contract under the Centers for Medicare & Medicaid Services (CMS). This individual is the primary day-to-day point of contact for CMS and is accountable for all aspects of contract performance, including delivery timelines, regulatory reporting, workforce management, and operational quality. The Program Director leads a large, 100+ multi-disciplinary team comprising clinical reviewers, medical coders, customer service staff, and IT personnel, ensuring all program activities meet or exceed contractual performance standards. This is a high-visibility, high-accountability role that demands deep expertise in Medicare Fee-for-Service (FFS) program operations, federal contracting environments, and large-scale healthcare program management.

Essential Duties and Responsibilities

• Serve as the single, accountable point of contact for CMS, including the Contracting Officer Representative (COR) and Contracting Officer (CO), on all contract matters.
• Own all contractual delivery timelines, ensuring on-time submission of all deliverables, reports, and performance data required by the SOW.
• Lead and manage a multi-disciplinary team including clinical reviewers, medical coders, customer service representatives, and IT staff; oversee hiring, training, performance management, and workforce planning.
• Monitor and ensure compliance with all contractual performance standards (including timeliness, accuracy, and provider communication requirements); proactively identify and resolve operational issues before they escalate.
• Oversee the development and submission of all required CMS reports, data deliverables, and program status updates in adherence to CMS reporting cadences.
• Lead contract kickoff activities, transition planning, and ongoing relationship management with CMS stakeholders including the COR and CO.
• Oversee Medicare Part A/B/DMEPOS claim review operations, including workflow design, case management systems, and quality assurance processes.
• Manage subcontractor relationships and performance in alignment with prime contract requirements.
• Champion a culture of compliance, accuracy, and continuous improvement across all program functions.

Qualifications

• Minimum 5 years of professional experience in healthcare program management, federal contracting, or a related field.
• Minimum 3 years of experience managing complex systems and workflows as a manager or supervisor.
• Minimum 3 years of experience in Medicare Fee-for-Service (FFS) program operations.
• Demonstrated experience managing teams of 100 or more staff in a federal healthcare contractor environment.
• Bachelor’s degree required; Master’s degree preferred. In lieu of a Master’s degree, 4 additional years of relevant experience may be substituted.

Preferred Qualifications

• Prior Program Director experience on a CMS medical review contract.
• Operational familiarity with Medicare Part A, Part B, and DMEPOS claim review processes and adjudication workflows.
• Working knowledge of CMS reporting cadences, contract kickoff processes, and the COR/CO relationship structure in a federal contracting environment.

Work Environment/Physical Demands?

The work environment and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This is an office/remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch.

Commence is an equal employment opportunity 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.

Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require a reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or hr@commence.ai.

Please note that unless you are requesting an accommodation, all applications must be submitted through our online application system.