OverviewResponsibilities
As the Medical Director, you will be 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, as well as serving as a public spokesperson for the CERT RC contract and the CERT program in general.
Responsibilities:
- Interacts with/presents to medical societies, peer groups, CMS Contractors and/or stakeholders and other industry groups, as a spokesperson for the CERT RC contract and the CMS CERT program.
- 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 CERT personnel.
- Provides medical insight and expertise for claims reviews conducted by specialty physicians and medical review specialists, in accordance with CMS policy and/or regulations and the CERT SOW/Manual.
- Makes claims determinations when warranted/requested, utilizing the guidelines, regulations, CMS policy, coding manuals and any other applicable/required resources.
- Collaborates with CERT management in advising CMS on national coverage and payment issues, as well as identifying and interpreting the improper payment rate drivers. In addition, it is expected that the CMD will provide insight into proposed policy or payment methodology changes, as well as any current or potential vulnerability to the CMS Medicare Program.
- Interacts with Medical Directors and other CMS contractors to share information and coordinate contractor policy development when appropriate.
- Maintains compliance with CMS procedures, guidelines, and CMS or contractor quality assurance feedback.
- 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
Requirements:
- Board-certified doctor of medicine or doctor of osteopathy currently licensed and has practiced medicine for at least four 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.
- 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 society9s participation in the Medicare program.
- Excellent organization, communication/collaboration and decision-making skills.
- Ability to work with others in a team environment.
- Ability to work with computer programs including MS Word, Excel, Sharepoint and Web-based meeting applications.
- Prior work experience in the health insurance industry, utilization review firm, or other health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines.
- Public relations experience such as working with physician groups, beneficiary organization and/or congressional offices.
Physical Requirements:
This position requires the ability to perform the below essential functions:
