The clinician serves as the final medical reviewer for complex and disputed CMS determinations, providing oversight for medical necessity and coverage decisions. Day-to-day work includes participating in provider dispute discussions, defending review findings in Administrative Law Judge hearings, and coordinating closely with clinical reviewers, project management, and legal counsel. The role is remote or office-based and centers on Medicare policy interpretation, documentation quality, and defensible decision-making.
Key Responsibilities
- Serve as the final clinical authority for complex, escalated, or disputed medical review determinations.
- Represent the program in Administrative Law Judge hearings and defend the clinical basis for review decisions.
- Participate in Discussion and Education sessions with providers and their representatives when disputes escalate.
- Provide clinical oversight and quality assurance for medical review determinations and documentation.
- Collaborate with the project manager, clinical reviewers, and operational leadership on issue resolution and program performance.
- Engage with CMS on policy interpretation, emerging coverage questions, and work group meetings.
- Maintain current knowledge of Medicare coverage policy, NCDs, LCDs, and relevant IOM guidance.
Required
- MD or DO degree.
- Board certification in a relevant specialty.
- Active, unrestricted U.S. medical license in good standing.
- At least 3 years of active post-residency clinical practice experience.
- Background in health insurance, utilization review, or healthcare claims processing.
- Strong familiarity with medical necessity and coverage determination standards.
Preferred
- Prior experience as a Contractor Medical Director or Medical Director for a CMS review contractor.
- Experience with Medicare coverage policy, NCDs, LCDs, and IOM 100-8 guidance.
- Experience representing cases at ALJ hearings or preparing written testimony for Medicare appeals.
- Multi-state medical licensure.
Benefits & Perks
- Remote or office-based work arrangement.
- Full-time position.
- Salary range of $275,000 to $375,000.
- Equal employment opportunity and reasonable accommodation support.