Medical Director – CMS Medical Review
Simsy Ventures
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteJob Level
Lead
About the role
- Oversee all aspects of medical review, validation activities, and quality assurance.
- Direct clinical personnel on correct application of Medicare policy during the validation process.
- Participate in CMS discussions, trainings, and policy interpretation sessions.
- Oversee training and education of RVC medical reviewers.
- Provide expert guidance on LCDs, NCDs, Medicare manuals, and all applicable medical policies.
- Serve as an expert resource during complex or questionable claim reviews.
- Monitor changes in medical practices and technology that may affect billing or improper payment risks.
- Recommend updates to LCDs, NCDs, system edits, and corrective actions based on RAC-identified vulnerabilities.
- Participate in CMS/RVC clinical workgroups and presentations as needed.
- Maintain compliance with conflict-of-interest reporting requirements.
- Ensure non-medical staff do not perform or oversee tasks requiring clinical judgment.
Requirements
- Minimum 3 years of clinical practice as a board-certified physician with no Medicare sanctions or exclusions.
- Minimum 2 years of experience in:
- Health insurance
- Utilization review
- Claims processing
- Medicare or federal healthcare program administration
- Extensive knowledge of Medicare coverage, billing, and payment rules.
- Experience working with physician groups, beneficiary organizations, and/or congressional offices preferred.
- Working knowledge of the CMS Fee-for-Service (FFS) Recovery Audit Program.
- Doctor of Medicine (MD) or Doctor of Osteopathy (DO), board-certified.
- Active, unrestricted license to practice medicine in a U.S. state or territory (verified annually).
Benefits
- Health insurance
- Professional development opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical practiceutilization reviewclaims processingMedicare coveragebilling rulespayment rulesLCDsNCDsCMS Fee-for-Service Recovery Audit Program
Soft skills
expert guidancetrainingeducationcommunicationleadership
Certifications
Doctor of Medicine (MD)Doctor of Osteopathy (DO)board certificationactive medical license