PROGRAM INTEGRITY MEDICAL REVIEW MANAGER

Program Integrity MR Manager

HMS is seeking a Program Integrity Medical Review Manager for an upcoming project focused on program integrity medical record reviews for federal payor programs. The MR Manager shall have primary responsibility for the development, oversight and implementation of the medical review program and related quality assurance processes of the Zone Program Integrity Contractor (ZPIC), Unified Program Integrity Contractor (UPIC), Medicare Drug Integrity Contractor (MEDIC) and Medicaid Integrity Coordinators (MIC). In addition, the Medical Review Manager shall have the primary responsibility for ensuring the timely submission of Program Integrity required reports.

Education/Licenses/Experience

• Board Certified in Nursing and licensed to practice nursing in the United States.
• Must be a licensed registered nurse.
• A minimum of five (5) years of clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice
• A minimum of two years of supervisory experience
• Task specific knowledge of the Medicare and Medicaid programs, particularly the coverage and payment rules
• Extensive knowledge of medical terminology; experience in the analysis and processing of Medicare and/or Medicaid claims and clinical review judgment is required
• Minimum of one year of experience in the medical review processes of Medicare Administrative Contractors (MAC), Supplemental Medical Review Contractor (SMRC), Comprehensive Error Rate Testing contractor (CERT), Qualified Independent Contractor (QICs) and Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs)
• Minimum of one year of medical review experience in Medicare and Medicaid Program Integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions in support of allegations of fraud, waste or abuse
• Minimum of one year of experience in the medical review processes of ZPICs/UPICs/MEDICs/MICs.

Program Description

The Center for Program Integrity (CPI) and other areas of the Centers for Medicare & Medicaid Services (CMS) collaborate with contractors to monitor the accuracy of Medicare and Medicaid medical review decision making, the ability to implement Medicare coverage, coding, payment, and billing policies and the identification of potential fraud, waste, or abuse. The goal of the program is to reduce payment error by preventing the initial payment of claims that do not comply with Medicare’s coverage, coding, payment, and billing policies.

EOE STATEMENT: Healthcare Management Solutions, LLC has established an Affirmative Action Plan. HMS is deeply committed to the concept and practices associated with equal opportunity and affirmative action in all aspects of employment. HMS makes clear that all applicants will be treated without regard to race, color, sex, religion, national origin, age, disability, genetic information, sexual orientation, ancestry, marital status, changes in marital status, pregnancy or parenthood, gender, or gender identity or expression, military or veteran status, political affiliation, or any other protected characteristics under applicable law when the reasonable demands of the position(s) do not require distinction on the basis of age, disability, sex, marital status, changes in marital status, pregnancy, or parenthood.

This company does not tolerate unlawful discrimination in its employment practices. We recognize the value of diversity in our workforce and encourage all qualified candidates to apply. We thank all candidates who choose to apply, however, only those selected for a further interview will be contacted.

Equal Opportunity Employer/M/F/Vet/Disabled. HMS is an EEO/AA/E-Verify compliant and drug free workplace employer.