Position Description & QualificationsThe 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 provides operational support to the Medical Review Manager and the Medical Review Staff in managing the production assignments related to claims determinations and review.
As a Medical Review Supervisor, you will:- Makes medical necessity determinations utilizing clinical review judgment in accordance with the CERT Program policies and contract responsibilities
- Serves as a resource for medical review specialists involving coverage, coding, and medical necessity issues
- Performs the third level of Medical Review in determination of claims payment review when the first and second level medical review determinations are in opposition
- Conducts in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles
- Applies the interpretation of ANSI Reason Codes, Revenue Codes, timely MAC Edits and Audit codes and other Medicare billing formats in determination of appropriate billing submissions and reimbursement
- Provides medical review specialist production assignments (quantity and type of claim review) to the IT department for the automated Assignment module as needed
- Provides medical review specialist claims production reports to the Medical Review Manager applying appropriate variance (fringe hours, QA, meeting time, etc.) statistics as needed
- Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines, as well as local medical review policies
- Provides research and updates to specialty claims review and review team needs
- Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields
- Reviews and completes referred level claim reviews in accordance to production standards for special studies as well as regular project claims for end of reporting requirements
- Provides training to integral staff and subcontractors for special studies as well as regular project claims review
- Complies with Program Integrity Manual (PIM) and Statement of Work (SOW) guidelines and CMS directives and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information
- Complies with departmental policies and procedures.
- Communicates internally with all levels of the CERT Program
- Attends departmental or required education and training programs
- Completes other projects or duties as assigned by the Medical Review Manager
To be successful in this role, you must have:- Excellent oral and written communication skills
- Knowledge of and the ability to use Microsoft Word, Excel, and Internet applications
- Team-oriented and able to implement the operational strategies and procedures that will help achieve the overall quality and production goals of the Medical Review unit
Additional desired qualifications:- 8-10 years of clinical experience in medical or surgical nursing
Pay TransparencyOur 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: [redacted].
