Medical Review Manager – CMS Medicare (RVC)

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The Medical Review (MR) Manager is responsible for overseeing all medical review activities and quality assurance functions for the CMS Review and Validation Contractor (RVC) program. This role ensures accurate application of Medicare policy, directs daily workflow for medical review staff, and supports the validation of Recovery Audit Contractor (RAC) determinations. The MR Manager must be available Monday–Friday, 8:00 AM to 4:30 PM ET. Work Schedule Monday through Friday 8:00 AM to 4:30 PM ET Availability required during these hours for CMS and operational needs

Manage and oversee medical review operations, including accuracy reviews, disputes, RAC topic evaluations, and special studies. Lead and supervise medical review staff to ensure proper application of Medicare policies and procedures. Provide clinical expertise and guidance for complex or questionable claim review situations. Conduct quality assurance (QA) audits to verify compliance with contract and regulatory requirements. Brief, train, and educate review personnel on policy interpretation and validation processes. Stay current on medical practice, technology changes, billing trends, and potential areas of improper payments. Ensure medical review activities align with CMS FFS Recovery Audit Program requirements. Serve as the clinical resource for Medicare coverage, documentation, coding, and regulatory requirements. Maintain timely communication with CMS and internal leadership as required. Ensure that all duties requiring clinical expertise are performed directly by the MR Manager; non-medical staff may not substitute.