Medical Director - Medicare Fee For Service

Medical Director- Medicare Fee For Service

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. National Government Services is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs. The Medical Director is responsible for drafting and developing policies for Medicare fee for service and assisting nurses as needed with review of claims. Works with other Medicare Administrative Contractor (MAC) Medical Directors for developing collaborative policies. May participate in MAC policy workgroups to review coverage criteria for existing services or new services and technology.

How You Will Make An Impact

Supports clinicians to ensure timely and consistent responses to providers. Provides guidance for clinical operational aspects of a program. Serves as a resource and consultant to other areas of the company; particularly the Medical Review and Appeals areas. May be required to represent the company to external entities and/or serve on internal and/or external committees. May chair company committees. Interprets medical policies and clinical guidelines. May develop and propose new medical policies based on changes in healthcare. Partner with The Center for Medicaid and Medicare Services (CMS) on inquiries and policy considerations.

Minimum Requirements

Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA). Must possess an active unrestricted medical license to practice medicine or a health profession. Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US. Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required. Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.

Preferred Qualifications

Medicare fee for service experience strongly preferred. This position is part of our NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.