Medical Director

2 weeks ago

Owings Mills, United States Neil Hoosier & Associates, Inc. Full time
Job DescriptionJob DescriptionNeil Hoosier & Associates, Inc. (NHA) is a small, SBA 8(a) certified and minority-owned business built on a tradition of reliability, accuracy, and responsiveness to the needs of our clients. We have delivered over 20 years of top-notch performance within the public sector, particularly for the Centers for Medicare & Medicaid Services (CMS), as well as for consulting firms, insurers, employers, and healthcare companies. Our talented staff offers business and IT solutions to Federal, State, and commercial organizations within the framework of a process improvement culture. We leverage our unrivaled expertise, extensive capabilities, and innovative solutions to ensure that our clients achieve their goals while saving money in the process.

NHA is seeking a Medical Director for an upcoming CERT Program opportunity.  This is a 100% remote work opportunity.Summary:          
The Comprehensive Error Rate Testing (CERT) program calculates the Medicare Fee-for-Service (FFS) program improper payment rate.  The CERT program was created to measure the error rate of improper Fee-for-Service payments.  The error rate measures payments that didn’t meet Medicare requirements.

Responsibilities:
The Contractor Medical Directors (CMDs) shall serve the functions of CMDs outlined in the CMS Internet-Only Manual (IOM) 100-8, Chapter 1, Section 1.4.   These primary duties include:
  • Leadership in the provider community, including interacting with medical societies and peer groups
  • Educating providers, individually or as a group, regarding identified problems or LCDs
  • Providing the clinical expertise and judgment to develop LCDs and internal MR guidelines
  • Serving as a readily available source of medical information to provide guidance in questionable claims review situations
  • Determining when LCDs are needed or must be revised to address program abuse
  • Assuring that LCDs and associated internal guidelines are appropriate
  • Briefing and directing personnel on the correct application of policy during claim adjudication, including through written internal claim review guidelines
  • Keeping abreast of medical practice and technology changes that may result in improper billing or program abuse
  • Providing the clinical expertise and judgment to effectively focus MR on areas of potential fraud and abuse; and Serving as a readily available source of medical information to provide guidance in questionable situations.
Other duties include: 
  • Interacting with the CMDs at other contractors to share information on potential problem areas
  • Participating in CMD clinical workgroups, as appropriate
  • Upon request, providing input to CO on national coverage and payment policy, including recommendations for relative value unit (RVU) assignments
Qualifications:
  • Doctor of Medicine or Doctor of Osteopathy Degree
  • Current licensure to practice medicine
  • A minimum of three (3) years of experience practicing medicine as a board-certified physician with no previous sanctioning or exclusion from the Medicare program
  • 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
  • Extensive knowledge of the Medicare program, particularly the coverage and payment rules
  • Public relations experience such as working with physician groups, beneficiary organizations, and/or congressional offices.


Employees that are hired for a position on a Federal Government contract may be subject to U.S. Office of Personnel Management (OPM) background checks at a Public Trust, or higher, level.  More information can be found here:

Background Investigations (dcsa.mil).
 

NHA is a state and federal government contractor; all employees must be legally authorized to work in the United States. NHA does not provide sponsorship at this time.

NHA is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability or any other basis protected by law.

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