Medical Director-First Coast

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.

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 perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform 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 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.

Collaboration and Leadership 30%
* 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 emphasis on decision consistency and clinical education of clinical staff through various mechanisms including but not limited to overseeing Inter-Reviewer Reliability (IRR) reviews.

Program Integrity 20%
* Support program integrity initiatives, including identifying trends in inappropriate billing practices or noncompliance.
* Collaborate with investigative teams and law enforcement when required.

Medical Review (MR) and Appeals 10%
* 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.

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 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. 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 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

Certifications, Licenses, Registration:
* 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

PREFERRED QUALIFICATIONS
* Experienced Physical Medicine and Rehabilitation (PM&R), Oncology, Radiology, or Ophthalmology 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