Medical Management Director jobs in Harrisburg, PA

Are you interested in joining a team of experienced healthcare experts and have the ability to shape and transform the healthcare delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 million Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a better health experience for all consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services.

Benefits info:
* 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

The Medicare Contractor Medical Director (CMD) provides medical leadership and decision making for First Coast/Novitas.

Job duties include but are not limited to:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.
* Serve as a readily available source of medical information to provide guidance to claim reviews across the organization, as well as conduct claim reviews as assigned
* Provide direction and assistance to clinical staff in conducting provider education, as well as assist in the development of clinical guidelines as needed
* 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
* Lead Local Coverage Determination (LCD) process to include development, revision, retirement, education and decision making
* Participate in all phases of LCD process
* Provide the clinical expertise and data management to effectively focus medical policy and reviews on identified problem areas
* Keep clinical knowledge up to date and abreast of medical practice and technology changes
* 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.
* Travel within and outside the First Coast/Novitas jurisdictions
* Participate in clinical workgroups as well as Medical Director national and regional forums
* Strengthen the quality improvement program 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
* Performs other duties as the supervisor may, from time to time, deem necessary

Job Requirements:
* MD or DO degree from accredited Medical School
* Minimum of three years clinical practice experience as an attending physician
* Knowledge, skill, and experience to evaluate clinical evidence, and to develop evidence-based medical necessity standards within the Medicare fee-for-service benefit structure
* Extensive knowledge of the Medicare program, particularly the coverage and payment rules
* 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 and utilization of services, as well as establishing enrollment criteria and educate providers
* Ability to work collaboratively with clinicians (i.e., nurses) as a team
* Ability and desire to educate team members and external entities (i.e., CMS, providers, other federal agencies, law enforcement, etc.)
* Computer literacy, including independent function using databases, word processing, spreadsheets, and internet
* Current, active, 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 Certification

Preferred:
* MBA, MHA, MS in Management or formal accredited coursework in medical systems management
* Demonstrated successful working relationship as a team member in previous workgroup
* Medical Director experience in Medicare related or commercial healthcare organization
* Coding and billing experience utilizing HCPCs, CPT, and ICD-10 codes

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.

This opportunity is open to remote work in the following approved states: AL, AK, FL, GA, ID, IN, IO, KS, KY, LA, MS, MO, 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, PA, TX and WI, in-office and hybrid work may also be available.

"We are an Equal Opportunity Employer/Protected Veteran/Disabled"