Medical Director

• 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 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 emphasis 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.
• 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.

• 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
  Performs other duties as the supervisor may, from time to time, 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.
   

• 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 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
  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
• 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
   

• 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) (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

johnb@arcgonline.com