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Job Description
Manager, Medical Affairs, Medicare Policy Operations About the opportunity: A healthcare organization is seeking a Manager, Medical Affairs to lead Medicare medical policy operations in a remote, exempt role. This position manages a specialized medical affairs and policy team supporting Medicare coverage policy, medical policy inquiries, claims-policy implementation, contractor pricing, CMS-facing reporting, stakeholder communication, and quality execution. This role is best suited for someone with strong Medicare policy or coverage operations experience, clinical fluency, and leadership experience across specialized, compliance-driven healthcare work.
What you will do:
Lead a medical affairs / medical policy team supporting policy nurses, analysts, consultants, and specialized personnel. Support Medicare medical policy operations, including local coverage work, policy research, revisions, reconsiderations, coding articles, communication, education, and effectiveness review. Partner with medical directors and internal stakeholders on complex clinical, coverage, coding, pricing, and policy-related inquiries. Help translate Medicare policy decisions into claims-processing workflows, claims edits, pricing activity, and operational guidance. Coordinate with claims, appeals, medical review, prior authorization, informatics, and other operational areas to support accurate implementation. Oversee contractor pricing activity for procedure codes and services not priced by CMS. Manage stakeholder communication involving providers, medical professionals, CMS-related stakeholders, internal teams, and other external parties. Track workload, assign deliverables, monitor timeliness, support team training, maintain quality controls, and lead process improvement efforts. Support compliance, root cause analysis, corrective action, reporting, and ongoing evaluation of departmental procedures.
Required qualifications:
Bachelor's degree. Five or more years of related Medicare work experience. Four or more years of direct supervisory experience, project management lead experience, or other leadership experience. RN background or nursing credential visible in work history or credentials, with license details to be verified during the recruiting process. Working knowledge of Medicare policies, procedures, and claims processing concepts. Clinical fluency, including comfort with medical issues, medical terminology, and medical, surgical, and diagnostic procedures. Ability to communicate confidently with medical professionals, providers, internal operational leaders, and external stakeholders. Strong analytical, problem-solving, decision-making, planning, organization, and time management skills. Professional communication style and ability to lead work in a compliance-focused environment.
Preferred qualifications:
Bachelor of Science in Nursing. Certified Professional Coder credential. Experience with Local Coverage Determinations, local coverage policy, coverage articles, or medical policy development. Experience with Medicare claims processing systems, claims edits, contractor pricing, reimbursement, or procedure code pricing. Experience working in a CMS contractor, Medicare Administrative Contractor, Medicare medical review, Medicare policy, or Medicare coverage operations environment. Experience with quality controls, CMS reporting, root cause analysis, corrective action, process improvement, or regulated healthcare reporting.
Compensation and work model:
Compensation:
Starting rate of $93,200 to the lower $100,000s.
Work model:
100% remote.
Status:
Exempt.
Start timing:
As soon as possible.
Location:
Candidate location will be verified against approved teleworking guidelines. Priority states include Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, and Texas.
How to apply:
Qualified candidates should submit a current resume for consideration. Candidates with Medicare policy, coverage operations, clinical policy, claims-policy implementation, contractor pricing, or CMS contractor experience are encouraged to apply.
