Medical Director

Seeking a Medical Director to join a fast growing organization. We are looking for candidates with background: in surgical specialties (any), ophthalmology, oncology, neurology, infectious diseases, or internal medicine Provide direction and assistance to clinical staff in conducting provider education, as well as assist in the development of clinical guidelines as needed. Keep clinical knowledge up to date and abreast of medical practice and technology changes. Serve as a subject matter expert in medical and clinical areas relevant to the Medicare program. Provide clinical consultation to internal teams (e.g., medical review staff, appeals teams) and external stakeholders. Provide the clinical expertise, scientific literature analysis, claims data analytics to effectively focus medical polical policy and reviews on identified problem areas. Collaborate with CMS and other Medicare Contractors (e.g., A/B or DME MACs and others) to develop and update medical policies and articles based on clinical evidence and regulatory requirements. Work with multidisciplinary teams within the MAC to improve processes and ensure compliance with CMS directives. Liaise with CMS staff, medical societies, and other stakeholders to align goals and address emerging issues. Represent the MAC at CMS meetings and industry conferences. Strengthen the quality improvement procedures with emplasis on decision consistency and clinical education of clinical staff through various mechanisms including but not limited to overseeing Inter-Reviewer Reliability (IRR) reviews. Support program integrity initiatives, including identifying trends in inappropriate billing practices or noncompliance. Ensure the proper application of Medicare regulations, national and local coverage determinations (NCDs and LCDs), and clinical guidelines. Participate in all phases of LCD development by leading the Local Coverage Determination (LCD) process to include development, revision, retirement, education, and decision making. Collaborate with investigative teams and law enforcement when required. Oversee medical review activities to ensure appropriate and consistent decisions on claim determinations including pre- and post-payment determinations. REQUIRED QUALIFICATIONS MD or DO degree from accredited Medical School Minimum of three years clinical practice experience as an attending physician Extensive knowledge of the Medicare program, particularly the coverage and payment rules Work experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines. Certifications, Licenses, Registration: Current, active, valid, unrestricted license to practice medicine in at least one state or territory within the United States, never suspended or revoked in any state or territory of the United States Board Certified Doctor of Medicine or a Doctor of Osteopathy in a specialty recognized by the American Board of Medical Specialties for at least three years #J-18808-Ljbffr