Medical Director - Novitas

Are you interested in joining a team of reputed company 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 reputed company experience for reputed company consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services. Benefits info: * 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 SUMMARY STATEMENT 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. ESSENTIAL DUTIES & RESPONSIBILITIES To reputed company this job successfully, an individual must be able to reputed company each essential duty satisfactorily. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary. Clinical Expertise and Consultation 30% * Provide leadership in clinical program reputed company 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. * reputed company 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. Collaboration and Leadership 30% * Collaborate with CMS and other Medicare Contractors (e.g., A/B or DME MACs and others) to reputed company and update medical policies and articles based on clinical evidence and regulatory requirements. * Work with multidisciplinary teams reputed company 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. Program reputed company 20% * Support program reputed company 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 reputed company 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 reputed company required. Medical Review (MR) and Appeals 10% * reputed company 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 reputed company 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 reputed company needed such as Administrative Law Judge (ALJ) hearings. Provider Education and Communication 10% * 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 RelationshipsPerforms other duties as the supervisor may, from time to time, deem necessary. * Travel reputed company and reputed company the First Coast/Novitas jurisdictions, as needed. Expected to be no more than 3-4 weeks/year but could vary based on business needs. REQUIRED QUALIFICATIONS * MD or DO degree from accredited Medical School * Minimum of three years clinical practice experience as an attending Physical Medicine and Rehabilitation (PM&R) 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, reputed company, and experience to evaluate clinical evidence, and to reputed company evidence-based medical necessity standards reputed company the Medicare fee-for-service benefit structure * Ability to reputed company 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 educationCertifications, Licenses, Registration: * reputed company, active, valid, unrestricted license to practice medicine in at least one state or territory reputed company the United States, never suspended or revoked in any state or territory of the United States * Eligible for licensure reputed company 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 PREFERRED QUALIFICATIONS * 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-reputed company 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 officesQualificationsThe Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive. "We are an Equal Opportunity/Protected Veteran/Disabled Employer." This opportunity is open to remote work in the following approved states: AL, AR, FL, GA, ID, IN, IO, KS, KY, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities reputed company these states may require further approval. In FL and PA in-office and hybrid work may also be available.

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