Medical Director - Novitas

GuideWell Source

18h • Remote

About The Position

Are you interested in joining a team of experienced healthcare experts and have
the ability to shape and transform the healthcare delivery system? At our family
of companies, everything we do is to help improve the lives of the nearly 12
million Medicare beneficiaries we serve and 700,000 health care providers who
care for them. It is our goal to help create a better health experience for all
consumers. Join our winning culture and help transform Medicare for the millions
of people who rely on its services.

The Medicare Contractor Medical Director (CMD) provides medical leadership and
decision making for First Coast/Novitas and serves as a liaison between the
Centers for Medicare and Medicaid Services (CMS) and stakeholders. CMDs play a
vital role in developing Local Coverage Determinations (LCDs) and ensuring
compliance with Medicare policies, reviewing medical claims, and promoting
evidence-based healthcare.

Requirements

• MD or DO degree from accredited Medical School
• Minimum of three years clinical practice experience as an attending physician
• Extensive knowledge of the Medicare program, particularly the coverage and payment rules
• Work 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.
• Knowledge, skill, and experience to evaluate clinical evidence, and to develop evidence-based medical necessity standards within the Medicare fee-for-service benefit structure
• Ability to develop strategies and processes to ensure evidence-based decision-making for policy in the Medicare population
• Basic understanding of medical coding conventions
• Ability to effectively communicate, collaborate with, and provide education on health care policy issues to both internal team members and external entities
• Ability to work collaboratively with internal staff to evaluate aberrancies, determine appropriate billing, coding, pricing, and utilization of services
• Proficiency with effective public speaking and ability educate providers
• Ability to work collaboratively with clinical and non-clinical team members
• Ability and desire to educate team members and external entities (i.e., CMS, providers, other federal agencies, law enforcement, etc.)
• Computer literacy, including proficiency using word processing, spreadsheets, presentation, and virtual meeting applications
• Ability to complete independent or computer-based training and education
• Current, active, valid, unrestricted license to practice medicine in at least one state or territory within the United States, never suspended or revoked in any state or territory of the United States
• Eligible for licensure within jurisdiction of First Coast/Novitas operations
• Board Certified Doctor of Medicine or a Doctor of Osteopathy in a specialty recognized by the American Board of Medical Specialties for at least three years

Nice To Haves

• Experienced Physical Medicine and Rehabilitation (PM&R), Oncology, Radiology, Ophthalmology, Cardiology, Surgical Specialties or Infectious Diseases professionals with five years of clinical practice
• MBA, MHA, MS in Management, or formal accredited coursework in medical systems management
• Demonstrated successful working experience in organized medicine group(s) (e.g., AMA, specialty society, state health department) as a committee chairperson or other leadership
• Medical Director experience in Medicare-related or commercial healthcare organization
• Coding and billing experience utilizing HCPCs, CPT, and ICD-10 codes
• Experience using GRADE methodology for literature analysis and performing systematic reviews
• Experience working with physician groups, beneficiary organizations, and/or congressional offices

Responsibilities

• Provide leadership in clinical program outreach to the practitioner/provider/supplier/beneficiary community.
• Provide direction and assistance to clinical staff in conducting provider education, as well as assist in the development of clinical guidelines as needed.
• Keep clinical knowledge up to date and abreast of medical practice and technology changes.
• Serve as a subject matter expert in medical and clinical areas relevant to the Medicare program.
• Provide clinical consultation to internal teams (e.g., medical review staff, appeals teams) and external stakeholders.
• Provide the clinical expertise, scientific literature analysis, claims data analytics to effectively focus medical polical policy and reviews on identified problem areas.
• Collaborate with CMS and other Medicare Contractors (e.g., A/B or DME MACs and others) to develop and update medical policies and articles based on clinical evidence and regulatory requirements.
• Work with multidisciplinary teams within the MAC to improve processes and ensure compliance with CMS directives.
• Liaise with CMS staff, medical societies, and other stakeholders to align goals and address emerging issues.
• Represent the MAC at CMS meetings and industry conferences.
• Strengthen the quality improvement procedures with emplasis on decision consistency and clinical education of clinical staff through various mechanisms including but not limited to overseeing Inter-Reviewer Reliability (IRR) reviews.
• Support program integrity initiatives, including identifying trends in inappropriate billing practices or noncompliance.
• Ensure the proper application of Medicare regulations, national and local coverage determinations (NCDs and LCDs), and clinical guidelines.
• Participate in all phases of LCD development by leading the Local Coverage Determination (LCD) process to include development, revision, retirement, education, and decision making.
• Collaborate with investigative teams and law enforcement when required.
• Oversee medical review activities to ensure appropriate and consistent decisions on claim determinations including pre- and post-payment determinations.
• Provide leadership in developing and implementing MR Quality Assurance Programs.
• Provide leadership in effectively focusing MR and developing internal MR guidelines.
• Review complex or high-level appeals and provide guidance on the application of Medicare policies.
• Provide support to the claim appeal process including assistance in the development of position papers and participation in the administrative process when needed such as Administrative Law Judge (ALJ) hearings.
• Provide leadership in the provider community (including interacting with hospital/specialty associations).
• Educate providers, individually or as a group, regarding identified problems or medical policy.
• Maintain Professional and Organization Relationships
• Performs other duties as the supervisor may, from time to time, deem necessary.
• Travel within and outside the First Coast/Novitas jurisdictions, as needed.

Benefits

• Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• Paid Time Off and Paid Sick Leave

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree