Medical Director National OP Medicare

About the role

Clinical judgment meets regulatory rules here: the work means reading records, applying CMS and national guidelines, and explaining decisions to internal staff and outside doctors.

At a glance

What you will do

• Review moderately complex to complex clinical cases on a computer and read all submitted records
• Decide whether requested services, level of care or site of service should be authorized
• Discuss cases by phone with external physicians to gather information or explain determinations
• Prioritize daily work and communicate decisions to internal associates
• Learn Medicare and Medicare Advantage rules and apply them day to day

What they look for

• MD or DO degree
• At least 5 years of direct clinical patient care after residency or fellowship, ideally with inpatient or Medicare population experience
• Current board certification in an ABMS or AOA specialty
• A current unrestricted license in at least one jurisdiction, with willingness to get more
• No federal or state sanctions and ability to pass credentialing
• Strong written and verbal communication and analytic skills

Nice to have

• Some experience with coding practices or clinical documentation