ARC Group has an immediate opportunity for a Medical Director! This position is 100% remote working eastern time zone business hours. This is a direct hire FTE position and a great opportunity to join a well-respected organization and have an impact on millions of lives and thousands of healthcare providers.

At ARC Group, we are committed to fostering a diverse and inclusive workplace where everyone feels valued and respected. We believe that diverse perspectives lead to better innovation and problem-solving. As an organization, we embrace diversity in all its forms and encourage individuals from underrepresented groups to apply.

100% REMOTE!

Candidates must currently have PERMANENT US work authorization. Sorry, but we are not considering any candidates from outside companies for this position (no C2C, 3rd party / brokering).

SUMMARY STATEMENT

The Medicare Contractor Medical Director (CMD) provides medical leadership and decision making for an organization that serves as a Medicare Administrative Contract (MAC). This role 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

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 emphasis 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

* Travel within and outside the assigned jurisdictions, as needed. Expected to be no more than 3-4 weeks/year but could vary based on business needs.

REQUIRED QUALIFICATIONS

* MD or DO degree from accredited Medical School

* Minimum of three years clinical practice experience as an attending Physical Medicine and Rehabilitation (PM&R) physician

* Extensive knowledge of the Medicare program, particularly the coverage and payment rules

* Work experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines.

* Knowledge, skill, and experience to evaluate clinical evidence, and to develop evidence-based medical necessity standards within the Medicare fee-for-service benefit structure

* Ability to develop strategies and processes to ensure evidence-based decision-making for policy in the Medicare population

* Basic understanding of medical coding conventions

* Ability to effectively communicate, collaborate with, and provide education on health care policy issues to both internal team members and external entities

* Ability to work collaboratively with internal staff to evaluate aberrancies, determine appropriate billing, coding, pricing, and utilization of services

* Proficiency with effective public speaking and ability educate providers

* Ability to work collaboratively with clinical and non-clinical team members

* Ability and desire to educate team members and external entities (i.e., CMS, providers, other federal agencies, law enforcement, etc.)

* Computer literacy, including proficiency using word processing, spreadsheets, presentation, and virtual meeting applications

* Ability to complete independent or computer-based training and education

Certifications, Licenses, Registration:

* Current, active, valid, unrestricted license to practice medicine in at least one state or territory within the United States, never suspended or revoked in any state or territory of the United States

* Eligible for licensure within jurisdiction of MAC operations

* Board Certified Doctor of Medicine or a Doctor of Osteopathy in a specialty recognized by the American Board of Medical Specialties for at least three years

PREFERRED QUALIFICATIONS

* MBA, MHA, MS in Management, or formal accredited coursework in medical systems management

* Demonstrated successful working experience in organized medicine group(s) (e.g., AMA, specialty society, state health department) as a committee chairperson or other leadership

* Medical Director experience in Medicare-related or commercial healthcare organization

* Coding and billing experience utilizing HCPCs, CPT, and ICD-10 codes

* Experience using GRADE methodology for literature analysis and performing systematic reviews

* Experience working with physician groups, beneficiary organizations, and/or congressional offices