Medical Review Manager

Remote
Full Time
Manager/Supervisor

This position is contingent upon the successful award of the associated contract. Employment is not guaranteed until the contract is awarded, and the position is officially activated. Job responsibilities and requirements are subject to change.

About J29:
J29, Inc. has been supporting commercial, State, and Federal health and human service programs since company inception in 2017. Our team of 240 employees focuses on providing claim, policy, and clinical analysis on end-to-end medical cases, disputes, appeals, and audits. Our team is experienced in program, payment, provider, and patient integrity as we continue to support advanced programs of policy, clinical requirements, and compliance measures at the commercial, State, and Federal levels.

J29 was founded to be an employee-centric company that prioritizes the well-being and value of its employees. Our mission is to empower our employees to do great things for the benefit of those that needs us most. The J29 mission supports not only our health and human service programs, but also the philanthropy efforts of our team. We are proud to continue our support to non-profit groups with critical missions as J29 continues to grow.

General Description:
Responsible for the overall medical review and quality assurance of the program review staff and associated processes. The MR Manager must be full-time and fully dedicated. The MR Manager shall be available between 8:00 am to 5:00 pm ET Monday-Friday. The MR Manager shall have extensive knowledge of the Medicare program and working knowledge of the program requirements and activities. 

Primary Duties Include but are not limited to: 

  • Briefing and directing personnel on the correct application of policy during the validation process. 
  • Educate review staff. 
  • Keeping abreast of medical practice and technology changes that may result in improper billing or program abuse. 
  • Serving as a readily available source of medical information to provide guidance in questionable claim review situations. 
  • Overseeing the medical review process and providing the clinical expertise and judgment to understand federal regulations and policy. 
  • Participating in random audits of reviewers to ensure cases are being reviewed in accordance with contract and regulatory requirements. 

Please Note: The MR Manager shall manage, direct, and be actively involved in Accuracy Reviews, Disputes, Special Studies, all aspects of the New Issue (NI) Review, and Contractor Quality Assurance. These tasks mentioned are not administrative and so non-medical personnel cannot be substituted for the MR Manager to oversee or perform any of the tasks that involve medical review. 

Work Experience: 
This candidate shall have at least five (5) years of previous medical review experience, with at least three (3) years’ experience as a MR Manager, and at least three years of medical review and quality assurance experience. 

Education and Licensure: 
The MR Manager shall have a current Registered Nurse (RN) license in the United States or U.S. Territory. An associate’s degree in nursing is acceptable. 

Job type: Full-Time
Location: Remote
#LI-remote

J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class.  J29, Inc. is a proud Veteran friendly employer. 

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