Medical Director - Novitas Solutions

Are you interested in joining a team of experienced healthcare experts and have the ability to shape and transform the healthcare delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 million Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a better health experience for all consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services.

Benefits info:
* Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
* Short- and long-term disability benefits
* 401(k) plan with company match and immediate vesting
* Free telehealth benefits
* Free gym memberships
* Employee Incentive Plan
* Employee Assistance Program
* Rewards and Recognition Programs
* Paid Time Off and Paid Sick Leave
 
SUMMARY STATEMENT
The Medicare Contractor Medical Director (CMD) provides medical leadership and decision making for First Coast/Novitas and serves as a liaison between the Centers for Medicare and Medicaid Services (CMS) and stakeholders. CMDs play a vital role in developing Local Coverage Determinations (LCDs) and ensuring compliance with Medicare policies, reviewing medical claims, and promoting evidence-based healthcare.

ESSENTIAL DUTIES & RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.
 
Clinical Expertise and Consultation 30%
* Provide leadership in clinical program outreach to the practitioner/provider/supplier/beneficiary community.
* Provide direction and assistance to clinical staff in conducting provider education, as well as assist in the development of clinical guidelines as needed.
* Keep clinical knowledge up to date and abreast of medical practice and technology changes.
* Serve as a subject matter expert in medical and clinical areas relevant to the Medicare program.
* Provide clinical consultation to internal teams (e.g., medical review staff, appeals teams) and external stakeholders.
* Provide the clinical expertise, scientific literature analysis, claims data analytics to effectively focus medical polical policy and reviews on identified problem areas.
 
Collaboration and Leadership 30%
* Collaborate with CMS and other Medicare Contractors (e.g., A/B or DME MACs and others) to develop and update medical policies and articles based on clinical evidence and regulatory requirements.
* Work with multidisciplinary teams within the MAC to improve processes and ensure compliance with CMS directives.
* Liaise with CMS staff, medical societies, and other stakeholders to align goals and address emerging issues.
* Represent the MAC at CMS meetings and industry conferences.
* Strengthen the quality improvement procedures with emplasis on decision consistency and clinical education of clinical staff through various mechanisms including but not limited to overseeing Inter-Reviewer Reliability (IRR) reviews.
 
Program Integrity 20%

* Support program integrity initiatives, including identifying trends in inappropriate billing practices or noncompliance.
* Ensure the proper application of Medicare regulations, national and local coverage determinations (NCDs and LCDs), and clinical guidelines.
* Participate in all phases of LCD development by leading the Local Coverage Determination (LCD) process to include development, revision, retirement, education, and decision making.

* Collaborate with investigative teams and law enforcement when required.
 

Medical Review (MR) and Appeals 10%
* Oversee medical review activities to ensure appropriate and consistent decisions on claim determinations including pre- and post-payment determinations.
* Provide leadership in developing and implementing MR Quality Assurance Programs.
* Provide leadership in effectively focusing MR and developing internal MR guidelines.
* Review complex or high-level appeals and provide guidance on the application of Medicare policies.
* Provide support to the claim appeal process including assistance in the development of position papers and participation in the administrative process when needed such as Administrative Law Judge (ALJ) hearings.
 
Provider Education and Communication 10%
* Provide leadership in the provider community (including interacting with hospital/specialty associations).
* Educate providers, individually or as a group, regarding identified problems or medical policy.
* Maintain Professional and Organization Relationships
Performs other duties as the supervisor may, from time to