Medical Review Manager Clinical Chart Validation

Overview

The Medical Review Manager (MRM) is responsible for coordinating the components of Clinical Chart Validation (CCV) reviews across audit staff, content staff, and associated processes. The MR Manager shall have broad knowledge of the CCV program and working knowledge of all non-Recovery Audit (RAC) lines of business requirements and activities. The MR Manager shall be responsible for keeping abreast of regulatory, policy, and coding changes as well as clinical practice, coding rules, and technology changes that may result in improper payments.

Responsibilities

• Overseeing the components of the CCV review process and providing clinical expertise and judgment to apply indications for coverage as outlined in Federal and state regulations and client policy.
• Overseeing the end-to-end processes for the CCV reviews.
• Educating and directing personnel on the correct application of review guidelines and concept logic during the review process.
• Serving as a liaison to the CMD related to claim reviews.
• 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.

Qualifications

• 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 8 years of related experience in healthcare; proven expertise within Hospital, Home Health, Hospice, DME, SNF or Physician Billing.

Base compensation ranges from $105,000 to $130,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration. 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: 05/30/2025 Applications are assessed on a rolling basis. We anticipate that the application window will close on 07/30/2025, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected. #LI-JB1 #LI-Remote #senior Apply Job!