Job Type
Full-time
Description
Requirements
We are seeking a board-certified physician to serve as Clinical Medical Director in support of CMS Healthcare Program. In this role, you will provide clinical leadership and medical expertise to support the federal independent dispute resolution (IDR) process ensuring that dispute resolution decisions are grounded in sound clinical standards, coding guidance, and medical necessity criteria.
This is a high-impact, policy-adjacent role combining clinical expertise with federal health program operations. The Clinical Medical Director will work closely with program management, legal, and analytical staff to support accurate, compliant, and defensible dispute resolution outcomes.
Key Responsibilities - Provide clinical oversight and medical subject matter expertise across program operations
- Review and adjudicate complex medical necessity, coding, and billing disputes involving out-of-network claims
- Develop and maintain clinical review protocols, decision frameworks, and quality standards
- Serve as the clinical authority on provider billing practices, medical coding (CPT, ICD-10), and insurance coverage determinations
- Advise program and legal staff on clinical aspects of IDR cases, including surprise billing policy interpretation
- Support development and delivery of training for clinical reviewers and case management staff
- Interface with CMS clinical policy staff as needed on program-level clinical questions
- Ensure clinical decisions are consistent with current guidelines, CMS policy, and applicable law (No Surprises Act, ERISA, state surprise billing laws)
Minimum Qualifications - M.D. or D.O. degree required; board-certified in a relevant specialty
- Active, unrestricted medical license; multi-state licensure a plus
- 5+ years of clinical practice experience post-residency
- 3+ years in a medical director, utilization management, or independent medical review role
- Strong working knowledge of CPT coding, medical billing, and insurance reimbursement processes
- Familiarity with utilization management criteria (InterQual, MCG/Milliman) and clinical appeals
- Experience with federal health programs (Medicare, Medicaid, or CHIP) preferred
- Excellent written and verbal communication; ability to produce clear, defensible clinical rationale documentation
- Must be eligible for CMS Public Trust (MBI) clearance
Preferred Qualifications - Direct experience with surprise billing, IDR, IRO, or IME (Independent Medical Examination) programs
- Background with CMS, health insurance exchange operations, or ACA regulatory environment
- Peer review or Independent Review Organization (IRO) experience
- Health law, compliance, or healthcare policy background (J.D. or MPH a plus)
*Commence' headquarters are in Virgina Beach, VA, however we are open to remote candidates in the following states: AZ, AR, DE, FL, GA, IL, IN, KS, KY, MA, MD, MI, MS, MO, MT, NC, NE, NV, NY, OH, OK, PA, SC, TN, TX, VA, DC, WI, and WV* 
