• Independently deliver all medical support required for successful delivery of the projects • Actively listen and address client feedback and suggestions regarding medical study-related activities • Provide medical expertise in Proposal Development Teams

• Lead Chamber’s core clinical programs (ToC, GDMT, Complex Care), ensuring adherence to evidence-based protocols and continuous improvement. • Supervise and mentor Nurse Practitioners and Care Coordinators, fostering excellence in patient-centered, protocol-driven care. • Develop and pilot new clinical programs, including emerging pathways • Ensure seamless collaboration with network cardiologists and other providers to align on standards of care and population goals. • Partner with Product, Engineering, and Analytics teams to design and test AI-enabled clinical tools, workflows, and dashboards. • Translate clinical needs into product specifications that streamline care delivery and measurement. • Lead clinical input into product roadmaps and new feature development to enhance patient and provider experience. • Evaluate and operationalize innovations that improve clinical efficiency and engagement. • Define and monitor metrics for outcomes, utilization, and medication adherence across programs. • Lead outcomes reviews and payer discussions focused on performance and impact. • Partner with analytics to identify opportunities for intervention, improvement, and automation. • Establish feedback loops between care teams, technology, and leadership to drive continuous improvement. • Work cross-functionally with Population Health, Operations, and Network teams to translate strategy into execution. • Serve as a clinical voice in payer, provider, and partner meetings to communicate Chamber’s value • Contribute to internal leadership discussions on care design, quality improvement, and program expansion.

• Oversee all aspects of clinical quality assurance • Develop and implement comprehensive training programs • Ensure compliance with regulatory requirements and HEDIS quality measures • Collaborate with Chief Medical Officer on quality improvement initiatives • Lead root cause analysis and corrective action planning • Build and maintain quality assurance programs with clear KPIs and reporting • Ensure compliance with state and federal regulations • Partner with Operations, Product, and Technology teams to optimize clinical workflows • Foster a culture of continuous improvement and clinical excellence

Role Description The Medicare Contractor Medical Director (CMD) provides medical leadership and decision making for First Coast/Novitas and serves as a liaison between the Centers for Medicare and Medicaid Services (CMS) and stakeholders. CMDs play a vital role in developing Local Coverage Determinations (LCDs) and ensuring compliance with Medicare policies, reviewing medical claims, and promoting evidence-based healthcare. Essential Duties & Responsibilities - Clinical Expertise and Consultation (30%) - Provide leadership in clinical program outreach to the practitioner/provider/supplier/beneficiary community. - Provide direction and assistance to clinical staff in conducting provider education, as well as assist in the development of clinical guidelines as needed. - Keep clinical knowledge up to date and abreast of medical practice and technology changes. - Serve as a subject matter expert in medical and clinical areas relevant to the Medicare program. - Provide clinical consultation to internal teams (e.g., medical review staff, appeals teams) and external stakeholders. - Provide the clinical expertise, scientific literature analysis, claims data analytics to effectively focus medical policy and reviews on identified problem areas. - Collaboration and Leadership (30%) - Collaborate with CMS and other Medicare Contractors (e.g., A/B or DME MACs and others) to develop and update medical policies and articles based on clinical evidence and regulatory requirements. - Work with multidisciplinary teams within the MAC to improve processes and ensure compliance with CMS directives. - Liaise with CMS staff, medical societies, and other stakeholders to align goals and address emerging issues. - Represent the MAC at CMS meetings and industry conferences. - Strengthen the quality improvement procedures 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. - Program Integrity (20%) - Support program integrity initiatives, including identifying trends in inappropriate billing practices or noncompliance. - Ensure the proper application of Medicare regulations, national and local coverage determinations (NCDs and LCDs), and clinical guidelines. - Participate in all phases of LCD development by leading the Local Coverage Determination (LCD) process to include development, revision, retirement, education, and decision making. - Collaborate with investigative teams and law enforcement when required. - Medical Review (MR) and Appeals (10%) - Oversee medical review activities to ensure appropriate and consistent decisions on claim determinations including pre- and post-payment determinations. - Provide leadership in developing and implementing MR Quality Assurance Programs. - Provide leadership in effectively focusing MR and developing internal MR guidelines. - Review complex or high-level appeals and provide guidance on the application of Medicare policies. - 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. - Provider Education and Communication (10%) - 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. - Maintain Professional and Organization Relationships. - Perform other duties as the supervisor may, from time to time, deem necessary. - Travel within and outside the First Coast/Novitas jurisdictions, as needed. Expected to be no more than 3-4 weeks/year but could vary based on business needs. Qualifications - MD or DO degree from accredited Medical School - Minimum of three years clinical practice experience as an attending physician - Extensive knowledge of the Medicare program, particularly the coverage and payment rules - Work experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines. - Knowledge, skill, and experience to evaluate clinical evidence, and to develop evidence-based medical necessity standards within the Medicare fee-for-service benefit structure - 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, coding, pricing, and utilization of services - Proficiency with effective public speaking and ability to educate providers - Ability to work collaboratively with clinical and non-clinical team members - Ability and desire to educate team members and external entities (i.e., CMS, providers, other federal agencies, law enforcement, etc.) - Computer literacy, including proficiency using word processing, spreadsheets, presentation, and virtual meeting applications - Ability to complete independent or computer-based training and education Requirements - Current, active, valid, 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 Certified Doctor of Medicine or a Doctor of Osteopathy in a specialty recognized by the American Board of Medical Specialties for at least three years Preferred Qualifications - Experienced Physical Medicine and Rehabilitation (PM&R), Oncology, Radiology, Ophthalmology, Cardiology, Surgical Specialties or Infectious Diseases professionals with five years of clinical practice - MBA, MHA, MS in Management, or formal accredited coursework in medical systems management - Demonstrated successful working experience in organized medicine group(s) (e.g., AMA, specialty society, state health department) as a committee chairperson or other leadership - Medical Director experience in Medicare-related or commercial healthcare organization - Coding and billing experience utilizing HCPCs, CPT, and ICD-10 codes - Experience using GRADE methodology for literature analysis and performing systematic reviews - Experience working with physician groups, beneficiary organizations, and/or congressional offices Benefits - 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 Additional Information - 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. - Background Investigation: If you are selected for this position, you must undergo a pre-employment Background Investigation, Drug Screen, and Identity Proofing documentation must be cleared prior to hire. - Identity Documentation: You must have access to a current and unrestricted REAL ID, U.S. Passport, U.S. Passport Card, Foreign Passport, or U.S. Permanent Residency Documents. Note: Employment Authorization Cards (EAD) are not a substitute for Visas or U.S. Permanent Resident Cards. - This opportunity is open to remote work in the following approved states: AL, AR, FL, GA, ID, IN, IO, KS, KY, LA, MS, 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 and PA in-office and hybrid work may also be available.