Medical Director (Medicare)

Responsibilities

• Interacts with/presents to medical societies, peer groups, CMS Contractors and/or stakeholders and other industry groups, as a spokesperson for the CERT RC contract and the CERT program in general.
• Maintains a current working knowledge of medical practice standards and guidelines and related technology.
• Aids in the development of contractor policy, including necessary updating of policies, and the development of written guidelines used by the CERT personnel.
• Provides medical insight and expertise for claims reviews conducted by specialty physicians and medical review specialists, in accordance with CMS policy and/or regulations and the CERT SOW/Manual.
• Makes claims determinations when warranted/requested, utilizing the guidelines, regulations, CMS policy, coding manuals and any other applicable/required resources.
• Collaborates with CERT management in advising CMS on national coverage and payment issues, as well as identifying and interpreting the improper payment rate drivers.
• Shares information and coordinates contractor policy development with Medical Directors and other CMS contractors when appropriate.
• Maintains compliance with CMS procedures, guidelines, and CMS or contractor quality assurance feedback.
• Coordinates medical specialty educational sessions for the staff when requested.
• Produces and submits required reports according to established content and guidelines.
• Effectively communicates with the customer, stakeholders, and employees.
• Performs other projects and responsibilities as assigned by the Program Director.

Qualifications

• Board-certified doctor of medicine or doctor of osteopathy currently licensed and has practiced medicine for at least four years.
• No adverse actions pending or taken against him/her by the Medicare, Medicaid, or any other Federal or State programs, any other medical insurance program, or medical licensing board.
• Extensive knowledge of the Medicare program, particularly the coverage and payment rules of the Medicare program.
• Does not hold office in any association (medical or specialty society) that promotes the interest of medical or specialty society’s participation in the Medicare program.
• Excellent organization, communication/collaboration and decision-making skills.
• Ability to work with others in a team environment.
• Ability to work with computer programs including MS Word, Excel, Sharepoint and Web-based meeting applications.
• Prior work experience in the health insurance industry, utilization review firm, or other health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines.
• Public relations experience such as working with physician groups, beneficiary organization and/or congressional offices.