Medical Director

About the role

The Contractor Medical Director (CMD) is responsible for researching and reviewing clinical evidence in support of developing Local Coverage Determinations (LCDs), conducting medical review (MR) activities, providing clinical program outreach activities, taking party or participant status in Administrative Law Judge (ALJ) appeals hearings, and performing appeals. The role collaborates with CMS and other Medicare Administrative Contractors (MAC) and interacts with medical societies and peer groups to share information, provide education and guidance. The CMD collaborates with multi-disciplinary teams to support accurate, timely, and consistent medical decision-making while promoting program integrity and high-quality care for Medicare beneficiaries.

Responsibilities

• Research and review clinical evidence in support of developing Local Coverage Determinations (LCDs).
• Work with RN(s) on local coverage determinations – reviewing new procedures that may involve new technology and provide medical judgment on coverage determinations.
• Meet with CMS staff to provide input/updates on coverage and MR policy issues and interact with the CMDs at other contractors to share information on potential problem areas.
• Work with the Medical Review (MR) Clinical Team to develop our MR strategy and provide clinical expertise to effectively focus MR on areas of potential fraud, waste, or abuse.
• Analyze data to determine if there is an aberrancy with a particular service or provider and identify opportunities for improvement or interventions to address the issues.
• Conduct claim reviews when appropriate and provide technical assistance on the correct application of MR policy during claim adjudication, including through written internal claim review guidelines.
• Serve as subject matter expert for law enforcement with investigations regarding fraudulent provider activity.
• Respond to inquiries from providers and representatives of the medical industry regarding advanced medical solutions that may provide better patient treatments and outcomes.

Requirements

Minimum Qualifications:

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Board Certification in an American Board of Medical Specialties recognized specialty.
• Possession of a valid active and unrestricted medical license (in any state or U.S. territory) with no federal sanctions.
• Five (5) or more years of experience as a practicing physician, with experience in Medicare insurance policies and regulations.
• Three (3) or more years of 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.
• Strong knowledge of evidenced-based medicine and clinical guidelines.
• Excellent written and verbal communication skills.

Preferred Qualifications

• Extensive knowledge of the Medicare Fee for Service program, particularly the coverage and payment rules, with Part A, Part B, DME, or Home Health and Hospice.

Benefits

• Performance bonus and/or merit increase opportunities.
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately).
• Competitive paid time off.
• Health insurance, dental insurance, and telehealth services start DAY 1.
• Professional and Leadership Development Programs.

Who We Are

We are WPS, a health solutions company, a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.

Culture

This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services.