• 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.

Dane Street is seeking experienced Board-Certified Physical Medicine & Rehab/Pain Management physicians to join our growing team of expert clinical reviewers. In this role, you will apply your expertise to conduct comprehensive reviews of clinical cases and provide objective, evidence-based medical opinions. This is a telework opportunity that allows you to customize your schedule while working as a 1099 independent contractor. Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to physical medicine & rehab/pain management care. Join a team that values your clinical judgment and commitment to improving the quality, accuracy, and consistency of healthcare assessments. Your expertise plays a vital role in supporting high-quality, defensible medical determinations.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Navitus Health Solutions is seeking a Pharmacist, Medicaid to join our team! The Pharmacist, Medicaid is responsible for providing Medicaid clinical, operational, and educational support to Navitus teams. This position will serve as a subject matter expert for Medicaid clinical aspects. The Pharmacist, Medicaid will provide operational support for the delivery of Medicaid clinical information to various business units throughout Navitus, interpretation of Medicaid guidance and state regulations, and support of Medicaid clinical operation processes. This position will be an active member of the Government Clinical Services Team within the Health Strategies Division. The ability to have strong regulatory knowledge related to Medicaid and the ability to concisely translate that for stakeholders and clients is a necessity. Responsibilities - Responsible for Medicaid clinical program development and maintenance, performance and outcomes monitoring, and consultative support. - Provide operational support to internal and external customers related to Medicaid clinical product offerings. - Provide clinical support for Medicaid related audits and requirements including but not limited to readiness reviews and administrative reviews. - Serve as a key stakeholder and decision-maker on implementation of new Medicaid clinical requirements. - Ensure compliance of Federal and State specific regulations as applicable to clients, including but not limited to the Social Security Act, the SUPPORT Act, and State Plans +/- Amendments. - Responsible for educating internal customers related to Medicaid regulations, programs, and audits. - Work with Government Programs and Formulary teams to assure timely and accurate submission of all formulary files and UM restrictions in accordance with CMS and state requirements. - Assist the Clinical Account Executive, Implementation, and Government Programs teams with new Medicaid implementations and with the annual re-implementations including support of the transition process to ensure clinical and operational functionality. - Serve as a clinical liaison to Navitus Government Programs teams and Clinical Account teams as needed. - Provide support for quality improvement projects per CMS requirements as needed. - Provide support for URAC clinical initiatives and projects as needed. - Collaborate with client vendors as requested by client. - Participate in, adhere to and support compliance and diversity, equity, and inclusion program objectives. - Other duties as assigned. Qualifications - Bachelor’s degree or Pharm. D required. - Registered pharmacist with current unrestricted licensure in the State of home office or the ability to gain reciprocity within 4 months. - Two years of PBM and/or Medicare Part D experience preferred. - Strong analytical capability. - Strong positive interpersonal skills to support staff development and retention. Benefits - Top of the industry benefits for Health, Dental, and Vision insurance. - 20 days paid time off. - 4 weeks paid parental leave. - 9 paid holidays. - 401K company match of up to 5% - No vesting requirement. - Adoption Assistance Program. - Flexible Spending Account. - Educational Assistance Plan and Professional Membership assistance. - Referral Bonus Program – up to $750!