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    Medical Director - Mechanicsburg, United States - Novitas Solutions

    Novitas Solutions
    Novitas Solutions Mechanicsburg, United States

    3 weeks ago

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    Description


    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

    The Medicare Contractor Medical Director (CMD) provides medical leadership and decision making for First Coast/Novitas.

    Job duties include but are not limited to:
    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.

    Serve as a readily available source of medical information to provide guidance to claim reviews across the organization, as well as conduct claim reviews as assigned

    Provide direction and assistance to clinical staff in conducting provider education, as well as assist in the development of clinical guidelines as needed

    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

    Lead Local Coverage Determination (LCD) process to include development, revision, retirement, education and decision making

    Participate in all phases of LCD process

    Provide the clinical expertise and data management to effectively focus medical policy and reviews on identified problem areas

    Keep clinical knowledge up to date and abreast of medical practice and technology changes

    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.

    Travel within and outside the First Coast/Novitas jurisdictions

    Participate in clinical workgroups as well as Medical Director national and regional forums

    Strengthen the quality improvement program 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

    Performs other duties as the supervisor may, from time to time, deem necessary


    Job Requirements:
    MD or DO degree from accredited Medical School

    Minimum of three years clinical practice experience as an attending physician

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

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

    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 and utilization of services, as well as establishing enrollment criteria and educate providers

    Ability to work collaboratively with clinicians (i.e., nurses) as a team

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

    Computer literacy, including independent function using databases, word processing, spreadsheets, and internet

    Current, active, 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 First Coast/Novitas operations

    Board Certification


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

    Demonstrated successful working relationship as a team member in previous workgroup

    Medical Director experience in Medicare related or commercial healthcare organization

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


    The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company.

    These years of residence do not have to be consecutive.


    This opportunity is open to remote work in the following approved states: AL, AK, FL, GA, ID, IN, IO, KS, KY, LA, MS, MO, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY.

    Specific counties and cities within these states may require further approval. In FL, PA, TX and WI, in-office and hybrid work may also be available.

    "We are an Equal Opportunity Employer/Protected Veteran/Disabled"

    #J-18808-Ljbffr
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