Medical Director – Medicare Policy & Clinical ReviewRemote | Full-Time
- We are seeking a Board-Certified MD or DO to serve as a Medical Director supporting Medicare medical policy, clinical review, coverage determinations, program integrity, and provider education. The ideal candidate will bring a strong background in Molecular Pathology or another targeted medical specialty, direct Medicare experience, and demonstrated leadership in areas such as developing and directing medical policy changes, leading clinical initiatives, managing cross-functional projects, and influencing coverage decisions. This position is particularly well suited for a physician with experience evaluating clinical evidence, developing Medicare coverage policy, working within Medicare-related healthcare organizations, and leading initiatives that impact medical necessity and coverage determinations.
Target Specialties
We are particularly interested in Board-Certified physicians with expertise in:
- Molecular Pathology
- Infectious Diseases
- Oncology
- Cardiology
- Surgical Specialties
Additional relevant specialties may also be considered based on Medicare policy and leadership experience.
Key Responsibilities
Medicare Medical Policy & Clinical Leadership
- Serve as a subject matter expert on clinical issues relevant to the Medicare program.
- Lead the development, revision, implementation, and retirement of Local Coverage Determinations (LCDs) and related medical policies.
- Evaluate clinical literature, scientific evidence, claims data, and utilization trends to develop evidence-based medical necessity standards.
- Provide clinical leadership regarding Medicare coverage, payment rules, medical necessity, and emerging technologies.
- Lead or direct policy changes, clinical projects, and strategic initiatives affecting Medicare populations.
- Maintain current knowledge of evolving medical practices, technologies, regulatory requirements, and clinical evidence.
Stakeholder Collaboration & Leadership
- Collaborate with government healthcare agencies, Medicare contractors, medical societies, physician organizations, and other healthcare stakeholders.
- Participate in multidisciplinary teams focused on Medicare policy, clinical review, compliance, and process improvement.
- Represent the organization during industry meetings, conferences, provider meetings, and other external forums.
- Provide education and guidance to internal clinical teams and external healthcare providers.
- Lead efforts to improve decision consistency and clinical quality, including oversight of Inter-Reviewer Reliability initiatives.
Medical Review & Appeals
- Provide leadership for pre-payment and post-payment medical review activities.
- Ensure consistent and appropriate application of Medicare regulations, National Coverage Determinations, Local Coverage Determinations, and clinical guidelines.
- Develop internal medical review guidelines and quality assurance processes.
- Review complex or escalated appeals and provide clinical guidance regarding Medicare policy application.
- Support the appeals process through development of clinical position papers and participation in administrative proceedings when needed.
Program Integrity
- Support initiatives focused on identifying inappropriate billing, utilization trends, coding concerns, and potential noncompliance.
- Work collaboratively with clinical, operational, investigative, and compliance teams to evaluate billing, coding, utilization, and medical necessity.
- Provide clinical expertise for Medicare program integrity initiatives.
- Collaborate with investigative teams or government agencies when appropriate.
Provider Education & Outreach
- Provide clinical leadership and education to physicians, hospitals, specialty associations, suppliers, and other healthcare organizations.
- Educate providers regarding Medicare policy, medical necessity requirements, billing trends, and identified areas of concern.
- Develop clinical guidance, presentations, and educational materials.
- Serve as a physician representative within the provider community.
Required Qualifications
- MD or DO from an accredited medical school.
- Current, active, unrestricted medical license in at least one U.S. state or territory.
- Board Certification in a recognized medical specialty for at least three years.
- Minimum of 3 years of clinical practice experience as an attending physician.
- Strong knowledge of the Medicare program, particularly coverage, medical necessity, reimbursement, and payment requirements.
- Experience within a health insurance organization, Medicare-related organization, utilization review organization, healthcare claims organization, or similar environment.
- Experience developing or interpreting medical coverage policies, medical necessity guidelines, or clinical review standards.
- Ability to critically evaluate medical literature and clinical evidence.
- Experience developing evidence-based medical necessity standards within the Medicare fee-for-service environment.
- Demonstrated ability to lead projects, initiatives, policy changes, or multidisciplinary clinical programs.
- Understanding of medical coding concepts, including CPT, HCPCS, and ICD-10.
- Strong written and verbal communication skills.
- Experience educating physicians, clinical staff, executives, or external stakeholders.
- Strong presentation and public-speaking abilities.
- Ability to collaborate effectively with clinical and non-clinical stakeholders.
Preferred Qualifications
- Molecular Pathology expertise strongly preferred.
- Approximately 5+ years of clinical practice experience.
- Previous Medical Director experience within a Medicare-related, health plan, or healthcare organization.
- Direct experience developing or managing LCDs, NCD-related policy, Medicare medical policy, or coverage determinations.
- Experience working with government healthcare programs or Medicare-related entities.
- Demonstrated leadership in organized medicine, including medical societies, healthcare committees, specialty organizations, or government healthcare organizations.
- Experience leading major clinical initiatives, policy implementation, quality programs, or cross-functional healthcare projects.
- Experience with HCPCS, CPT, and ICD-10 coding and billing.
- Experience using GRADE methodology, systematic literature reviews, or other formal evidence-assessment methodologies.
- MBA, MHA, MS in Management, or other formal training in healthcare or medical systems management.
- Experience working with physician groups, beneficiary organizations, government agencies, or other external healthcare stakeholders.
EOC
Ascendo is a certified minority owned staffing firm, and we welcome and celebrate diversity. Ascendo is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, parental status, military service or any other characteristic protected by federal, state or local law
