Medical Director/Spokesperson
About the Role
The Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) program plays a vital role in safeguarding the integrity of the Medicare Fee-for-Service (FFS) program by ensuring that taxpayer-funded healthcare payments are accurate, appropriate, and compliant with federal requirements. Supporting CMS's obligations under the Payment Integrity Information Act (PIIA), the program uses statistically valid sampling and independent medical review of claims to identify improper payments and measure program performance. The insights generated through CERT enable CMS to strengthen accountability, improve healthcare delivery practices, and drive corrective actions that protect both beneficiaries and public funds. Through this work, the CERT program helps uphold transparency, stewardship, and trust in one of the nation's most critical healthcare systems.
This position is responsible for the provision of medical insight and expertise for Medicare claims review determinations and national coverage and payment issues under the direction of the Program Director.
Responsibilities
- Interacts with medical societies, peer groups and other industry groups
- Maintains a current working knowledge of medical practice standards and guidelines and related technology
- Assists in the development of contractor policy, including necessary updating of policies, and the development of written guidelines used by the PSC CERT personnel
- Provides medical insight and expertise for the claims reviews conducted by specialty physicians and medical review specialists
- Makes claims determinations when warranted
- Collaborates with management in advising CMS on national coverage and payment issues
- Interacts with the Medical Directors at other CMS contractors to share information and coordinate contractor policy development when appropriate
- Ensures compliance of specialty physicians with PSC procedures, guidelines and quality assurance activities
- Ensures compliance with quality management system and ISO requirements
- 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 three 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
Skills
- 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, and decision-making skills
- Ability to work with others in a team environment
- Ability to work with computer programs including MS Word and Excel
Benefits
Comprehensible benefits for full-time employees (part-time employees receive a limited package tailored to their role):
- Medical, dental, and vision insurance
- Robust vacation and sick leave benefits, and flexible work arrangements where permitted by role or contract
- 401(k) plan that includes employer matching funds
- Tuition reimbursement program
- Life insurance and disability coverage
- Optional coverages that can be purchased, including pet insurance, home and auto insurance, additional life and accident insurance, critical illness insurance, group legal, ID theft protection
- Birth, adoption, parental leave benefits
- Employee Assistance Plan