Description
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- 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.
$120,000 - $180,000 a year
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