Medical Director – Medicare

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Empower AI

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1989

Empower AI helps federal agency leaders elevate their workforce productivity. We leverage deep technical expertise and decades of experience solving complex challenges in Civilian and Defense missions to ensure America’s missions are met. Our solutions give government leaders a direct path to meaningful transformation, equipping them with the insights and tools necessary to make critical decisions faster and move their missions forward.

📋 Description

• 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. • 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. • 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.

🎯 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. • 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 society’s 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.

🏖️ Benefits

• Competitive salary • Professional development opportunities