[Hiring] Medical Director @American Recruiting & Consulting Group

Role Description

The Medicare Contractor Medical Director (CMD) provides medical leadership and decision making for an organization that serves as a Medicare Administrative Contractor (MAC). This role 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 and developing 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 clinical expertise, scientific literature analysis, and 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 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 quality improvement procedures with emphasis on decision consistency and clinical education of clinical staff through various mechanisms.
• 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 LCD process including 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.
• 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 organizational relationships.
  • Perform other duties as the supervisor may deem necessary.
  • Travel within and outside the assigned 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 enterprise 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 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) 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.

Company Description

ARC Group is a Forbes-ranked top 20 recruiting and executive search firm working with clients nationwide to recruit the highest quality technical resources. We have achieved this by understanding both our candidate's and client's needs and goals and serving both with integrity and a shared desire to succeed.

At ARC Group, we are committed to providing equal employment opportunities and fostering an inclusive work environment. We encourage applications from all qualified individuals regardless of race, ethnicity, religion, gender identity, sexual orientation, age, disability, or any other protected status. If you require accommodations during the recruitment process, please let us know.