Manager, Medical Affairs; Medicare Medical Policy

An established healthcare administrative services organization is seeking a Manager, Medical Affairs to lead a fully remote Medicare medical policy team. This leader will oversee the development, implementation, and ongoing maintenance of coverage policies that guide coding, billing, claims processing, reimbursement, and provider education.

The strongest candidates have worked where clinical evidence and Medicare requirements become written policy and operational rules. Direct Local Coverage Determination or Medicare Administrative Contractor experience is valuable. Comparable experience in payer medical policy, payment policy, coding policy, or payment integrity may also align when it includes policy ownership, Medicare depth, and leadership.

The position centers on policy development and implementation. Medical Review experience is relevant when it includes policy, coding, claims, quality, or program ownership.

What You Will Lead:

• Lead a multidisciplinary team that may include policy nurses, research analysts, pricing consultants, business analysts, medical research consultants, and other specialized personnel.
• Oversee clinical evidence research and the development, revision, maintenance, and communication of Medicare medical and coverage policies.
• Manage Local Coverage Determination activities, including proposed and final policies, reconsiderations, revisions, retirements, and related coverage and billing articles.
• Translate policy decisions into coding guidance, claims edits, reimbursement logic, contractor pricing, system requirements, operational workflows, and staff education.
• Partner with Contractor Medical Directors on complex clinical, coverage, coding, pricing, reimbursement, and policy questions.
• Oversee stakeholder engagement, including provider and physician communication, Contractor Advisory Committee activities, and CMS-required Open Meetings.
• Assign and track policy, pricing, coding, clinical, and medical-director inquiries while managing workload, deadlines, quality, training, and team performance.
• Lead quality controls, root cause analysis, corrective action, process improvement, departmental procedures, and timely CMS reporting.

Required Qualifications:

• Registered Nurse professional background. Current RN license status will be verified during the selection process.
• At least five years of related Medicare experience.
• At least four years of direct supervision, project leadership, program leadership, or comparable experience with accountability for people, deliverables, implementation, quality, or regulated operational outcomes.
• Experience developing, revising, owning, or operationalizing medical, coverage, payment, coding, claims-edit, reimbursement, or related Medicare policy.
• Knowledge of how Medicare policy connects to medical necessity, coding, claims processing, reimbursement, pricing, and operational implementation.
• Ability to evaluate clinical and regulatory information, make sound decisions, and communicate effectively with physicians, medical directors, providers, CMS stakeholders, and operational teams.
• Strong planning, organization, problem-solving, written communication, and team-leadership skills.

Relevant experience may come from Medicare Fee-for-Service, Medicare Advantage, a Medicare Administrative Contractor, another CMS contractor, payer medical policy, payment integrity, clinical policy coding, reimbursement, or audit-concept development. Comparable experience should show a clear connection among Medicare requirements, written policy or decision rules, claims or coding impact, and accountable leadership.

Preferred Qualifications:

• Bachelor of Science in Nursing.
• Certified Professional Coder credential.
• Direct Medicare Administrative Contractor, Local Coverage Determination, or CMS-contractor experience.
• Experience with MCS, FISS, Medicare claims edits, contractor pricing, coverage and billing articles, or related policy systems and outputs.
• Experience supporting Contractor Medical Directors or leading Contractor Advisory Committee, Open Meeting, provider-education, or external stakeholder activities.
• Experience leading quality controls, corrective action, regulated reporting, and process improvement through staff or cross-functional teams.

Compensation and Work Model:

• Base salary of $100,000 to $115,000.
• 10 percent bonus opportunity.
• Fully remote within approved hiring locations. Location eligibility will be confirmed during the process.
• Exempt status.
• Target start date as soon as possible.