Senior Medical Reviewer
Core
Supervise a team of RN Medical Reviewers supporting Medicare medical review operations, ensuring compliance with CMS requirements and managing daily workload distribution.
Role type
Senior IC nursing supervisor (Medicare medical review)
Builds
Medicare medical review operations for federal agencies (CMS, VA, DoD)
Domain
Healthcare administration + Medicare utilization review
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Team supervision, workload distribution, case turnaround monitoring, fraud/aberrant billing escalation, virtual desk audit execution, mentorship, documentation, independent decision-making
Preferred skills
Home health RCD or MAC medical review experience, pre-claim review documentation familiarity, CMS program integrity experience across multiple jurisdictions
Technologies
Case management systems
Responsibilities
Directly supervise a team of approximately 20 RN Medical Reviewers, managing day-to-day case assignment and workload distribution; Monitor case turnaround daily against the 7-business-day requirement and rebalance workload to prevent bottlenecks; Flag cases at risk of missing turnaround and reassign or escalate; Confirm and escalate provider concerns, suspected fraud, and data/privacy incidents; Conduct periodic virtual desk audits of remote work environments; Mentor newly onboarded RN Medical Reviewers; Report turnaround performance and staffing risk to the Project Manager daily
Seniority
Senior, hands-on IC