Medical Director

WPS—A health solutions company · Madison, WI · 6 days ago

HybridFull-time

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

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.

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.

Skills

Strong research and analysis skills.
Effective communication and collaboration skills.
Ability to work independently and as part of a team.
Proficiency in using relevant software and tools for medical review and data analysis.

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.

Pay

Salary Range: $275,000 - $300,000 (may be higher based on experience)

Schedule

Hybrid work 2 days per week, with occasional travel to WPS Headquarters (1717 W. Broadway in Madison, WI, 53713) and CMS conferences.

Location

First preference for employment is in the state of Wisconsin for hybrid work and collaboration. Employees within 45 miles of WPS Headquarters will be expected to work Hybrid 2 days a week on a regular basis. As a secondary consideration, remote work is available in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin. Occasional travel to WPS Headquarters and CMS conferences may be expected.

How do I know this opportunity is right for me?

If you enjoy the following: 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.

Remote Work Requirements

A wired (ethernet cable) internet connection from your router to your computer.
A high speed cable or fiber internet.
A minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net).

About WPS

We are a health solutions company, a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. 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. We have been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.

Culture

We drive our success with a culture that fosters an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. We are proud of the recognition we have received from local and national organizations regarding our culture and workplace.