Job Description

Job Title: Medicare Contractor Medical Director (CMD)

Position Summary:

The Medicare Contractor Medical Director (CMD) provides medical leadership and decision-making in support of the Medicare program. This role serves as a liaison between the Centers for Medicare & Medicaid Services (CMS) and stakeholders, with responsibility for developing Local Coverage Determinations (LCDs), ensuring compliance with Medicare policies, reviewing medical claims, and advancing evidence-based healthcare practices.

Key Responsibilities:

Clinical Expertise & Consultation (30%)

• Lead clinical program outreach to providers, suppliers, and beneficiaries.
• Direct and assist in provider education and the development of clinical guidelines.
• Stay current with medical practice and technology advancements.
• Serve as a subject matter expert in clinical areas relevant to Medicare.
• Provide consultation to internal staff and external stakeholders.
• Utilize scientific literature and claims data analytics to inform medical policy and reviews.

Collaboration & Leadership (30%)

• Partner with CMS and other Medicare contractors to develop and update policies.
• Work with cross-functional teams to improve processes and ensure compliance.
• Liaise with CMS staff, medical societies, and stakeholders on emerging issues.
• Represent the organization at CMS meetings and industry events.
• Oversee quality improvement processes, ensuring consistency and education across teams.

Program Integrity (20%)

• Identify trends in inappropriate billing practices and support compliance efforts.
• Ensure adherence to Medicare regulations, NCDs, LCDs, and guidelines.
• Lead the full LCD development lifecycle, including revisions and provider education.
• Collaborate with investigative teams and law enforcement when appropriate.

Medical Review & Appeals (10%)

• Oversee medical review activities for claim determinations.
• Guide the development of Medical Review Quality Assurance Programs.
• Review complex appeals and support the appeals process, including ALJ hearings.
• Develop and implement internal medical review guidelines.

Provider Education & Communication (10%)

• Engage with providers and associations to deliver education on medical policy.
• Educate providers on identified problem areas through one-on-one or group sessions.
• Maintain strong professional and organizational relationships.
• Travel as needed (typically 3–4 weeks per year).

Required Qualifications:

• MD or DO degree from an accredited medical school.
• Minimum of 3 years of clinical practice as an attending physician.
• In-depth knowledge of Medicare coverage and payment rules.
• Experience in health insurance, claims processing, or utilization review involving policy and guideline development.
• Ability to evaluate clinical evidence and develop evidence-based coverage standards.
• Strong communication and collaboration skills with internal and external stakeholders.
• Public speaking and provider education experience.
• Proficiency in MS Office and virtual meeting platforms.
• Current, active, unrestricted license to practice medicine in at least one U.S. state or territory.
• Board certification in a specialty recognized by the American Board of Medical Specialties for at least three years.

Preferred Qualifications:

• 5+ years of clinical practice in PM&R, Internal Medicine, Oncology, Radiology, Ophthalmology, or Infectious Diseases.
• Advanced degree (MBA, MHA, MS in Management) or coursework in medical systems management.
• Leadership experience in organized medicine or professional associations.
• Medical Director experience in Medicare or commercial healthcare.
• Coding and billing expertise (HCPCS, CPT, ICD-10).
• Experience with GRADE methodology and systematic reviews.
• Experience working with physician groups, beneficiary organizations, or congressional offices.

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

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