Medical Director
ARC Group
Jacksonville, FL
MEDICAL DIRECTOR - REMOTE
ARC Group has an immediate opportunity for a Medical Director! This position is 100% remote working eastern time zone business hours. This is a direct hire FTE position and a fantastic opportunity to join a well-respected organization and have a positive impact on the lives of millions of people. At ARC Group, we are committed to fostering a diverse and inclusive workplace where everyone feels valued and respected. We believe that diverse perspectives lead to better innovation and problem-solving. As an organization, we embrace diversity in all its forms and encourage individuals from underrepresented groups to apply. 100% REMOTE!Candidates must currently have PERMANENT US work authorization. Sorry, but we are not considering any candidates from outside companies for this position (no C2C, 3 rd party / brokering). SUMMARY STATEMENT
The Medicare Contractor Medical Director (CMD) provides medical leadership and decision making for an organization that serves as a Medicare Administrative Contractor (MAC). This role 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%
ARC Group has an immediate opportunity for a Medical Director! This position is 100% remote working eastern time zone business hours. This is a direct hire FTE position and a fantastic opportunity to join a well-respected organization and have a positive impact on the lives of millions of people. At ARC Group, we are committed to fostering a diverse and inclusive workplace where everyone feels valued and respected. We believe that diverse perspectives lead to better innovation and problem-solving. As an organization, we embrace diversity in all its forms and encourage individuals from underrepresented groups to apply. 100% REMOTE!Candidates must currently have PERMANENT US work authorization. Sorry, but we are not considering any candidates from outside companies for this position (no C2C, 3 rd party / brokering). SUMMARY STATEMENT
The Medicare Contractor Medical Director (CMD) provides medical leadership and decision making for an organization that serves as a Medicare Administrative Contractor (MAC). This role 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 polical policy and reviews on identified problem areas.
- 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.
- 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.
- 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.
- 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
Performs other duties as the supervisor may, from time to time, deem necessary. - Travel within and outside the assigned jurisdictions, as needed. Expected to be no more than 3-4 weeks/year but could vary based on business needs.
- 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 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
Certifications, Licenses, Registration: - 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 enterprise 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
- Experienced Physical Medicine and Rehabilitation (PM&R), Oncology, Radiology, Ophthalmology 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
Posted 2025-11-06
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