[Hiring] Medical Director @GuideWell Source

Role Description

The Medicare Contractor Medical Director (CMD) provides medical leadership and decision making for First Coast/Novitas and serves as a liaison between the Centers for Medicare and Medicaid Services (CMS) and stakeholders. CMDs play a vital role in developing Local Coverage Determinations (LCDs) and ensuring compliance with Medicare policies, reviewing medical claims, and promoting evidence-based healthcare.

Essential Duties & Responsibilities

• Clinical Expertise and Consultation (30%)
  • Provide leadership in clinical program outreach to the practitioner/provider/supplier/beneficiary community.
  • 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 policy and reviews on identified problem areas.
• Collaboration and Leadership (30%)
  • 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 emphasis on decision consistency and clinical education of clinical staff through various mechanisms including but not limited to overseeing Inter-Reviewer Reliability (IRR) reviews.
• Program Integrity (20%)
  • 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.
• Medical Review (MR) and Appeals (10%)
  • Oversee medical review activities to ensure appropriate and consistent decisions on claim determinations including pre- and post-payment determinations.
  • Provide leadership in developing and implementing MR Quality Assurance Programs.
  • Provide leadership in effectively focusing MR and developing internal MR guidelines.
  • Review complex or high-level appeals and provide guidance on the application of Medicare policies.
  • Provide support to the claim appeal process including assistance in the development of position papers and participation in the administrative process when needed such as Administrative Law Judge (ALJ) hearings.
• Provider Education and Communication (10%)
  • Provide leadership in the provider community (including interacting with hospital/specialty associations).
  • Educate providers, individually or as a group, regarding identified problems or medical policy.
  • Maintain Professional and Organization Relationships.
  • Perform other duties as the supervisor may, from time to time, deem necessary.
  • Travel within and outside the First Coast/Novitas jurisdictions, as needed. Expected to be no more than 3-4 weeks/year but could vary based on business needs.

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.
• Knowledge, skill, and experience to evaluate clinical evidence, and to develop evidence-based medical necessity standards within the Medicare fee-for-service benefit structure
• Ability to develop strategies and processes to ensure evidence-based decision-making for policy in the Medicare population
• Basic understanding of medical coding conventions
• Ability to effectively communicate, collaborate with, and provide education on health care policy issues to both internal team members and external entities
• Ability to work collaboratively with internal staff to evaluate aberrancies, determine appropriate billing, coding, pricing, and utilization of services
• Proficiency with effective public speaking and ability to educate providers
• Ability to work collaboratively with clinical and non-clinical team members
• Ability and desire to educate team members and external entities (i.e., CMS, providers, other federal agencies, law enforcement, etc.)
• Computer literacy, including proficiency using word processing, spreadsheets, presentation, and virtual meeting applications
• Ability to complete independent or computer-based training and education

Requirements

• 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
• Eligible for licensure within jurisdiction of First Coast/Novitas operations
• 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

Preferred Qualifications

• Experienced Physical Medicine and Rehabilitation (PM&R), Oncology, Radiology, Ophthalmology, Cardiology, Surgical Specialties or Infectious Diseases professionals with five years of clinical practice
• MBA, MHA, MS in Management, or formal accredited coursework in medical systems management
• Demonstrated successful working experience in organized medicine group(s) (e.g., AMA, specialty society, state health department) as a committee chairperson or other leadership
• Medical Director experience in Medicare-related or commercial healthcare organization
• Coding and billing experience utilizing HCPCs, CPT, and ICD-10 codes
• Experience using GRADE methodology for literature analysis and performing systematic reviews
• Experience working with physician groups, beneficiary organizations, and/or congressional offices

Benefits

• Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• Paid Time Off and Paid Sick Leave

Additional Information

• The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive.
• Background Investigation: If you are selected for this position, you must undergo a pre-employment Background Investigation, Drug Screen, and Identity Proofing documentation must be cleared prior to hire.
• Identity Documentation: You must have access to a current and unrestricted REAL ID, U.S. Passport, U.S. Passport Card, Foreign Passport, or U.S. Permanent Residency Documents. Note: Employment Authorization Cards (EAD) are not a substitute for Visas or U.S. Permanent Resident Cards.
• This opportunity is open to remote work in the following approved states: AL, AR, FL, GA, ID, IN, IO, KS, KY, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require further approval. In FL and PA in-office and hybrid work may also be available.