Aged Care, Auditing, C Programming Language, Centers for Medicare and Medicaid Services (CMS), Communication Skills, Continuous Improvement, Contract Requirements, Customer Satisfaction, Data Analysis, Government Regulations, Healthcare, Leadership, Medicare, Medicine, Patient Care, Quality Assurance, Quality Monitoring, Regulations, Reimbursement, Root Cause Analysis, Section 125 Pre-Tax Plan, Staff Motivation, Time Management
LOCATION
Austin, Texas
POSTED
3 days ago
Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.
*This position is located Remote Anywhere US*
*This position requires a credit check*
Position Purpose:
Provides physician leadership and quality oversight for the task order or project.
Essential Responsibilities:
Direct Leadership over Physician Reviewers. Responsible for productivity, production, and quality of the decisions for second level appeals related to Medicare Part C (e.g., Medicare Advantage Organizations, Medicare cost plans, health care prepayment plans, and Programs of All-inclusive Care for the Elderly (PACE)).
Provide leadership in support of accurate and timely processing of higher level appeals (reconsiderations) related to Medicare Part C.
Provides executive leadership to Physician Reviewers and oversees their productivity, production, and decision letter quality.
Oversees, directs and monitors quality and continuous improvement of the quality assurance program.
Performs quality audits of physician reviews.
Ability to communicate health care appeal issues to various stakeholders
Motivate and align staff, processes, and tools to meet contract requirements, government regulations, and provide good customer satisfaction.
Develops and monitors reports and data analysis to identify root causes of items that should be improved to improve the overall medical program.
Minimum Qualifications
Education
Graduate of an accredited medical school
License and Certification
Active State license to practice medicine
Board certification
Experience
Ten (10) years clinical
Five (5) years demonstrated and progressively responsible medical managerial or leadership role
At least 5 years of direct Medicare experience working as a medical director, physician reviewer, or other senior medical position within an organization that provides services under Medicare Part C (e.g., Medicare Advantage Organizations, Medicare cost plans, health care prepayment plans, and Programs of All-inclusive Care for the Elderly (PACE)). (Per Contract Requirements)
Three (3) years of experience as a physician reviewer on Medicare Part C appeals (Per Contract Requirements)
Extensive knowledge of the Medicare program, including the coverage and payment rules of Medicare Part C
Knowledge of Medicare regulations, claims administration, and medical review processes
No federal or state sanctions as would appear on reporting from the National Practitioner Data Bank (NPDB)
Currently have or have had direct patient care within the last three years
Experience interpreting and implementing CMS guidelines and regulatory updates related to Medicare Advantage, preferred
Benefits
C2C offers an excellent benefits package, including:
Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance