Medical Director – CMS Medical Review

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Simsy Ventures

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B2B • Startup • Sustainability

Simsy Ventures is a venture builder and institutional co-founder that partners with entrepreneurs, investors, and corporations to create sustainable startups. Their mission focuses on enabling startups to achieve true potential while promoting a positive impact on profits, people, and the planet. With a structured approach, they support startups throughout their lifecycle, from ideation to market validation and growth. By leveraging a repeatable venture studio model, Simsy Ventures aims to uplift economies globally through impactful entrepreneurship.

11 - 50 employees

Founded 2022

🤝 B2B

📋 Description

• Oversee all aspects of medical review, validation activities, and quality assurance. • Direct clinical personnel on correct application of Medicare policy during the validation process. • Participate in CMS discussions, trainings, and policy interpretation sessions. • Oversee training and education of RVC medical reviewers. • Provide expert guidance on LCDs, NCDs, Medicare manuals, and all applicable medical policies. • Serve as an expert resource during complex or questionable claim reviews. • Monitor changes in medical practices and technology that may affect billing or improper payment risks. • Recommend updates to LCDs, NCDs, system edits, and corrective actions based on RAC-identified vulnerabilities. • Participate in CMS/RVC clinical workgroups and presentations as needed. • Maintain compliance with conflict-of-interest reporting requirements. • Ensure non-medical staff do not perform or oversee tasks requiring clinical judgment.

🎯 Requirements

• Minimum 3 years of clinical practice as a board-certified physician with no Medicare sanctions or exclusions. • Minimum 2 years of experience in: • Health insurance • Utilization review • Claims processing • Medicare or federal healthcare program administration • Extensive knowledge of Medicare coverage, billing, and payment rules. • Experience working with physician groups, beneficiary organizations, and/or congressional offices preferred. • Working knowledge of the CMS Fee-for-Service (FFS) Recovery Audit Program. • Doctor of Medicine (MD) or Doctor of Osteopathy (DO), board-certified. • Active, unrestricted license to practice medicine in a U.S. state or territory (verified annually).

🏖️ Benefits

• Health insurance • Professional development opportunities