Position Overview: We are seeking an experienced and dedicated Medical Director – Medicare Claims and Policy Review to lead and oversee the development, evaluation, and implementation of medical necessity policies and coverage guidelines related to Medicare programs. This individual will play a critical role in ensuring adherence to federal regulations, improving claims processing efficiency, and driving clinical integrity in utilization review practices. This position is fully remote.
\n Responsibilities:Policy Development and Oversight:Lead the creation and revision of coverage policies, guidelines, and procedures to ensure compliance with Medicare regulations and standards.Collaborate with stakeholders to evaluate the clinical appropriateness of policies, including defining criteria for medical necessity and coverage.Claims Review and Analysis:Provide expert clinical guidance and oversight for complex Medicare claims and appeals, ensuring adherence to established policies and medical necessity standards.Analyze claims data to identify trends, areas for improvement, and opportunities to enhance claims adjudication processes.Regulatory Compliance:Maintain up-to-date knowledge of Medicare laws, regulations, and guidelines, and ensure organizational policies are aligned with current requirements.Serve as the primary clinical liaison with regulatory agencies, including CMS (Centers for Medicare & Medicaid Services).Clinical Leadership:Offer clinical expertise to support utilization review and case management teams in making evidence-based decisions.Serve as a resource for medical staff, claims processors, and other personnel, providing education on Medicare coverage policies and medical necessity guidelines.Stakeholder Collaboration:Partner with internal teams, including compliance, legal, and operations, to implement effective claims processing strategies.Engage with external stakeholders, such as healthcare providers and industry groups, to address concerns and clarify policy interpretations.Quality Improvement:Develop and oversee quality assurance programs to ensure the accuracy and efficiency of claims processing and policy application.Identify and implement strategies to reduce claim denials and appeals while maintaining compliance and clinical integrity.
\n$120,000 - $180,000 a year
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