Description:
The Medical Director is the senior physician on a CMS program and the final clinical authority for complex medical review determinations. The CMD provides direct oversight of clinical review quality, participates in Discussion and Education (D&E) sessions when providers escalate disputes to the physician level, and represents CMS at Administrative Law Judge (ALJ) hearings to defend review decisions. The CMD works closely with the Project Manager, clinical review staff, and legal counsel to ensure the integrity and defensibility of all program medical determinations.
Essential Duties And Responsibilities
- 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).
Qualifications
- 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.