Medical Review Manager Government Services

Overview:

The Medical Review Manager (MRM) is responsible for the overall medical review and quality assurance of the CCV RAC review staff and associated processes. The MR Manager shall have broad knowledge of the Medicare program and working knowledge of the CMS FFS Recovery Audit Program requirements and activities. The MR Manager shall be responsible for keeping abreast of regulatory, policy, and coding changes as well as clinical practice and technology changes that may result in improper payments. 

• Overseeing the medical review process and providing the clinical expertise and judgment to apply indications for coverage as outlined in Federal regulations and policy. 
• Overseeing the end-to-end processes for the CCV RAC review 
• Educating and directing personnel on the correct application of CMS-issued review guidelines and edit parameters during the review process. 
• Serving as a liaison to the CMD related to claim reviews. 
• Overseeing the Inter-Rater Reliability (IRR) process. 
• Assuring the timely and accurate completion of the review topic QA processes. 
• Acts as a subject matter expert regarding reimbursement methodologies and applicable regulations.
• Remains abreast of industry / client trends and anticipates potential impact to the team; understands the relationship between regulatory changes and impact to new / existing concepts and reviews and supports the development of this understanding / vision with team members.
• Coordinates activities of all stakeholders across the CCV Review.
• Complete all responsibilities as outlined in the annual performance review and/or goal setting.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and requirements of the job change.

• Bachelor’s degree in Nursing required or an equivalent combination of Associates degree and 2 years of relevant experience.
• AHIMA / AAPC coding certification (CPC, CPC-H, or CCS) required.
• Current Registered Nurse (RN) license in the United States or U.S. Territory required.
• Minimum of 5 years of experience in auditing medical records; experience at Cotiviti or a similar payment integrity company required.
• Minimum of 3 years management experience required.
• Minimum of 8 years of related experience in healthcare; proven expertise within Hospital, Home Health, Hospice, DME, SNF or Physician Billing.
• Proficient in Microsoft Word, Excel (including Pivot tables), Access, Outlook, etc. with excellent written and verbal communication skills with demonstrated ability to mentor and teach other employees.
• Proficient with Medicare reimbursement methodologies, billing guidelines, and applicable industry-based
• Proficient with all healthcare coding (CPT4, HCPCS, DRG, ICD-9 and ICD-10, Home Health, SNF, Modifiers, Revenue Codes, etc.).
• Proficient with healthcare claim adjudication standards
• Demonstrated ability to perform critical thinking and problem solving with strong ability to simultaneously manage and delegate multiple tasks, work plans, and priorities.
• Self-motivated to exceed service goals for quality, timeliness, and efficiency.
• Ability to influence stakeholders, resolve conflicts, and drive decision-making processes effectively.

Mental Requirements:

• Communicating with others to exchange information.
• Problem-solving and thinking critically.
• Completing tasks independently.
• Interpreting data.
• Making timely decisions in the context of a workflow.
• Maintaining focus.
• Assessing the accuracy, neatness and thoroughness of the work assigned.
• Learning new tasks and completing tasks in situations that have a speed or productivity quota.
• Remembering and adhering to processes and protocols.
• Applying established protocols in a timely manner.

Working Conditions and Physical Requirements:

• Remaining in a stationary position, often standing, or sitting for prolonged periods.
• Communicating with others to exchange information.
• Repeating motions that may include the wrists, hands and/or fingers.
• Assessing the accuracy, neatness and thoroughness of the work assigned.
• No adverse environmental conditions expected.
• Must be able to provide a dedicated, secure work area.
• Must be able to provide high-speed internet access / connectivity and office setup and maintenance.

Base compensation ranges from $100,000 to $125,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. 

Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.

Date of posting: 1/27/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 3/1/2025, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.