Clinical Medical Director

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LivantaLLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2004

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

Livanta LLC is a technology-enabled organization dedicated to advancing healthcare quality through innovation. It specializes in providing services to patients, caregivers, healthcare providers, and payers, focusing on improving health outcomes, navigating healthcare systems, and ensuring payment accuracy. Livanta is recognized as the largest Medicare Quality Improvement Organization and offers a range of services including quality oversight, auditing, advocacy, and data analytics to enhance patient care and safety while managing healthcare costs effectively.

📋 Description

• Serve as the final clinical authority for complex, disputed, or escalated medical review determinations across the CMS program. • Represent the program at Administrative Law Judge (ALJ) hearings; testify and defend the clinical basis for review determinations. • Minimum 10 ALJ appearances per month required. • Participate in Discussion and Education (D&E) sessions with providers and their representatives when disputes are escalated to the physician level. • Provide clinical oversight and quality assurance across the medical review function, ensuring determinations are consistent, well-documented, and defensible under Medicare coverage policy. • Actively engage with CMS on issue resolution, medical review policy interpretation, and emerging coverage questions; participate in CMS meetings and work groups as required. • Collaborate with the Project Manager, clinical reviewers, and operational leadership to support program performance, staff education, and continuous quality improvement. • Maintain currency with Medicare coverage policies, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and relevant IOM guidance (including IOM 100-8).

🎯 Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO); board-certified in a relevant specialty. • Currently licensed to practice medicine in the United States; licensure must remain active and in good standing throughout employment. • Minimum 3 years of active medical practice experience post-residency. • Background in health insurance, utilization review, or healthcare claims processing, including familiarity with medical necessity criteria and coverage determination standards. • Demonstrated capacity for active, substantive engagement in medical review activities, issue resolution, and CMS-directed meetings — this position requires consistent hands-on participation and is not a nominal or figurehead role. • Prior Contractor Medical Director or Medical Director experience at a CMS review contractor preferred. • In-depth familiarity with Medicare coverage policy, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Internet-Only Manual guidance, including IOM 100-8 preferred. • Experience participating in or leading ALJ hearing representation in a Medicare appeals context, including preparation of written testimony and presentation of clinical evidence preferred. • Multi-state medical licensure preferred given the nationwide scope of review activities.