Medical Review Manager

Position Description & Qualifications

The Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) program plays a vital role in safeguarding the integrity of the Medicare Fee-for-Service (FFS) program by ensuring that taxpayer-funded healthcare payments are accurate, appropriate, and compliant with federal requirements. Supporting CMS’s obligations under the Payment Integrity Information Act (PIIA), the program uses statistically valid sampling and independent medical review of claims to identify improper payments and measure program performance. The insights generated through CERT enable CMS to strengthen accountability, improve healthcare delivery practices, and drive corrective actions that protect both beneficiaries and public funds. Through this work, the CERT program helps uphold transparency, stewardship, and trust in one of the nation’s most critical healthcare systems.

This position is responsible for the management of the Medical Review Department under the direction of the Program Director.

In this role, you will:

• Review and complete sampled Medicare claims
• Conduct in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM/PCS, CPT-4, and HCPCS Level II coding principles
• Supervise the determinations made by medical review specialists and lead medical review specialists for payment of claims to identify errors
• Ensure that claims review meets the standards defined by the Statement of Work, the Program Integrity Manual, and CMS directives and regulations pertaining to Medical Review
• Perform fourth level review of claims determination when submitted by lead medical review specialists
• Ensure departmental compliance with quality management system and ISO requirements
• Meet quality and production standards
• Monitor the quality of reviews and department productivity
• Monitor the Medicare Administrative Contractors (MAC) Feedback Coordinator actions and responses to MACs
• Develop, approves, implements and ensures department compliance with Medical Review (MR) policies and procedures 
• Communicate with the CMS Contracting Officer Representative (COR) regarding MR issues
• Communicate with the MAC MR Managers regarding Medicare claims payment issues
• Develop and provides educational presentations for national Medicare conferences
• Make hiring decisions and manages the Medical Review unit staff
• Determine and coordinates the education and training necessary for the department staff
• Produce and submits required reports according to established content and time guidelines
• Effectively communicates with the customer, stakeholders and employees
• Perform other projects and responsibilities as assigned by Program Director 

To be successful in this role, you must have:

• Bachelor's degree
• Graduate from an accredited Registered Nurse (RN) school with active state licensure
• 4 years in a supervisory/management position.
• 4 years clinical experience in a medical/surgical setting.
• 4 years experience in medical/utilization review or fraud investigation.
• 4 years experience in Medicare prospective payment systems. 
• No adverse actions pending or taken against him/her by any State or Federal licensing board or program; and must have no un-mitigated conflict of interest (COI) 
• Effective interpersonal, problem solving and communication (both written and verbal) skills
• Ability to work with others in a team environment 
• Working knowledge of Microsoft Word, Excel, and Internet applications 
• Expertise with determining medical review responses on medical review decisions based on Medicare coverage and reimbursement policies 

Additional desired qualifications:

• Certification as a CCS (Certified Coding Specialist) and CCS-P (Certified Coding Specialist- Physician Based) preferred.

If you are interested in supporting a passionate Serco team - then submit your application now for immediate consideration. It only takes a few minutes and could change your career!

Company Overview

Serco Inc. (Serco) is the Americas division of Serco Group, plc. In North America, Serco’s 9,000+ employees strive to make an impact every day across 100+ sites in the areas of Defense, Citizen Services, and Transportation. We help our clients deliver vital services more efficiently while increasing the satisfaction of their end customers. Serco serves every branch of the U.S. military, numerous U.S. Federal civilian agencies, the Intelligence Community, the Canadian government, state, provincial and local governments, and commercial clients. While your place may look a little different depending on your role, we know you will find yours here. Wherever you work and whatever you do, we invite you to discover your place in our world. Serco is a place you can count on and where you can make an impact because every contribution matters.

To review Serco benefits please visit: https://careers.serco-na.com/us/en/what-we-offer. If you require an accommodation with the application process please email: [email protected] or call the HR Service Desk at 800-628-6458, option 1. Please note, due to EEOC/OFCCP compliance, Serco is unable to accept resumes by email.

Candidates may be asked to present proof of identify during the selection process. If requested, this will require presentation of a government-issued I.D. (with photo) with name and address that match the information entered on the application. Serco will not take possession of or retain/store the information provided as proof of identity. For more information on how Serco uses your information, please see our Applicant Privacy Policy and Notice.

Serco does not accept unsolicited resumes through or from search firms or staffing agencies without being a contracted approved vendor. All unsolicited resumes will be considered the property of Serco and will not be obligated to pay a placement or contract fee. If you are interested in becoming an approved vendor at Serco, please email [email protected].

Serco is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.

Pay Transparency

Our Total Rewards package includes competitive pay, performance-based incentives, and benefits that promote well-being and work-life balance—so you can thrive both professionally and personally. Eligible employees also gain access to a wide range of benefits from comprehensive health coverage and health savings accounts to retirement plans, life and disability insurance, and time-off programs that support work-life balance. Program availability may vary based on factors such as contract type, location, hire date, and applicable collective bargaining agreements.

Salary range: The range for this position can be found at the top of this posting. This range is provided as a general guideline and represents a good faith estimate across all experience levels. Actual base salary will be determined by a variety of factors, including but not limited to, the scope of the role, relevant experience, job-related knowledge, education and training, key skills, and geographic market considerations. For roles available in multiple states, the range may vary to reflect differences in local labor markets. In addition to base salary, eligible positions may include other forms of compensation such as annual bonuses or long-term incentive opportunities. Benefits – Comprehensible benefits for full-time employees (part-time employees receive a limited package tailored to their role):

• Medical, dental, and vision insurance
• Robust vacation and sick leave benefits, and flexible work arrangements where permitted by role or contract
• 401(k) plan that includes employer matching funds
• Tuition reimbursement program
• Life insurance and disability coverage
• Optional coverages that can be purchased, including pet insurance, home and auto insurance, additional life and accident insurance, critical illness insurance, group legal, ID theft protection
• Birth, adoption, parental leave benefits
• Employee Assistance Plan

To review all Serco benefits please visit: https://careers.serco-na.com/us/en/about-us.

Serco complies with all applicable state and local leave laws, including providing time off under the Colorado Healthy Families and Workplaces Act for eligible Colorado residents, in alignment with our policies and benefit plans. The application window for this position is for no more than 60 days. We encourage candidates to apply promptly after the posting date, as the position may close earlier if filled or if the application volume exceeds expectations. Please submit applications exclusively through Serco’s external (or internal) career site. If an applicant has any concerns with job posting compliance, please send an email to: [email protected].