Program Integrity Medical Review Manager Job at Williams Consulting LLC in Caton

Williams Consulting, LLC is seeking a candidate who can work in a Hybrid mode occasionally at our  Catonsville, MD office as a Program Integrity Medical Review Manager for a Program supporting the Centers for Medicare & Medicaid Services (CMS). The hours are Monday-Friday 8:30pm-5:00pm. 

Williams Consulting, LLC is an 8a, HUBZone located, and Woman-owned Small Business with Federal, State, Local and Commercial clients. We take great pride in our ability to provide exceptional customer service and we value our employees and recognize their contributions to the success of our clients and our company. We offer competitive salaries and support flexible work locations and scheduling, when possible. We offer competitive benefits including Medical, Vision, and Dental coverage through national plans. We also offer Life, AD&D, Short- & Long-Term Disability Insurance, PTO, and 401k.

Description

Williams Consulting, LLC is seeking an experienced Medical Review Manager to manage the delivery of a mission-critical Federal program. The Medical Review Manager will work with the Contract Medical Director to plan, implement and evaluate the Medical Review and quality control/quality assurance processes.

Responsibilities

• Development, oversight, and implementation of the medical review program to include team leadership and routine interactions with CMS.
• Development, oversight, and implementation of related QC/QA processes.
• Responsible for ensuring the timely submission of Program Integrity (PI) required reports.
• Program Integrity Security Compliance

Qualifications

• Board Certified in Nursing and licensed to practice nursing in the United States, and a currently licensed RN.
• Minimum of five years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice.
• Minimum of three years of supervisory experience supporting Medicare Part A and B payment reviews focused on coverage, policy and payment rules, including the review of of Medicare beneficiary medical records and claims using clinical review judgment.
• Minimum of 5 years of medical review experience in Medicare PI 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 and abuse.
• Extensive experience in the medical review processes of either the CERT, Comprehensive Error Rate Testing Accuracy effort, the Unified Program Integrity Contractor effort,  or the Supplemental Medical Review Contractor (SMRC) effort  
• Extensive knowledge of medical terminology.
• Experience in the analysis and processing of Medicare and Medicaid claims including clinical review judgment.
• Strong analytical, problem-solving, and decision-making capabilities.
• Proven ability to meet deadlines and work on multiple projects simultaneously.
• Superior verbal and written communication skills to include stakeholder audience definition and messaging.
• Advanced MS Office (Project, Visio, Word, Excel, PowerPoint, Outlook) skills.
• Able to pass background investigation.

Williams Consulting, LLC does not discriminate in employment based on race, color, religion, sex, national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factors.Bottom of Form