Medical Director (MD/DO)
Location: Jacksonville, FL
Job Type: Direct Placement
Company: ARC Group
Category: Administration
Job Description Apply Now
Medical Director (MD/DO) Position OverviewARC Group is seeking a dedicated and experienced Medical Director (MD/DO) for a full-time, remote employment opportunity. The Medical Director (MD/DO) role is vital in providing medical leadership and expertise for organizations serving as Medicare Administrative Contractors (MAC). This key position functions as a crucial liaison between the Centers for Medicare and Medicaid Services (CMS) and various stakeholders, ensuring that all processes align with current Medicare guidelines and best practices. The Medical Director (MD/DO) will play a leading role in the development of Local Coverage Determinations (LCDs), compliance initiatives, and the promotion of evidence-based healthcare policies.
Key Responsibilities- Provide clinical leadership and expertise within the Medicare program, including outreach to practitioners, providers, suppliers, and beneficiaries.
- Guide and support clinical staff in provider education initiatives and the creation of clinical guidelines as required.
- Maintain up-to-date clinical knowledge, staying informed on medical practice advancements and technology changes.
- Serve as a subject matter expert on medical and clinical issues relevant to Medicare.
- Consult with internal teams (such as medical review and appeals staff) and external stakeholders on complex clinical matters.
- Analyze scientific literature and claims data to inform policy development and focus medical reviews effectively.
- Collaborate with CMS and other Medicare Contractors to develop and update medical policies and supporting articles based on clinical evidence and regulatory requirements.
- Work with multidisciplinary teams to ensure compliance with CMS directives and to improve internal processes.
- Represent the organization at CMS meetings, industry conferences, and strengthen quality improvement procedures.
- Lead program integrity initiatives, identifying and addressing trends in inappropriate billing or noncompliance, and ensuring proper application of Medicare regulations.
- Oversee all phases of LCD development, including creation, revision, retirement, education, and decision-making.
- Collaborate with investigative teams and law enforcement when required.
- Direct medical review activities to ensure consistent and appropriate claim determinations, including pre- and post-payment reviews.
- Develop and implement Medical Review (MR) Quality Assurance Programs and internal MR guidelines.
- Review complex appeals and provide expert guidance on Medicare policy application.
- Support the claims appeal process, including developing position papers and participating in administrative proceedings as needed.
- Lead provider education efforts, interact with hospital and specialty associations, and educate providers about medical policy and regulatory changes.
- Maintain professional relationships and perform additional duties as needed by supervision.
- Travel up to 3-4 weeks per year may be required based on business needs.
- MD or DO degree from an accredited medical school.
- At least three years of clinical practice experience as an attending physician.
- Extensive knowledge of the Medicare program, including coverage and payment rules.
- Experience in the health insurance industry, utilization review, or healthcare claims processing organization in a policy development role.
- Ability to evaluate clinical evidence and develop evidence-based medical necessity standards within Medicare fee-for-service structure.
- Proficiency in developing strategies for evidence-based policy in the Medicare population.
- Basic understanding of medical coding conventions.
- Strong communication, collaboration, and educational skills for both internal and external audiences.
- Experience working collaboratively to evaluate billing, coding, pricing, and utilization of services.
- Public speaking proficiency and ability to educate healthcare providers.
- Ability to work effectively with clinical and non-clinical teams, and a desire to educate team members and external stakeholders including CMS and law enforcement.
- Computer literacy, including proficiency with word processing, spreadsheets, presentations, and virtual meeting applications.
- Capability to complete independent or computer-based training and education.
- Current, active, valid, unrestricted license to practice medicine in at least one U.S. state or territory, with eligibility for licensure within the relevant jurisdiction.
- Board Certification in a specialty recognized by the American Board of Medical Specialties for at least three years.
- Experience in Physical Medicine and Rehabilitation (PM&R), Oncology, Radiology, Ophthalmology, or Infectious Diseases with five years of clinical practice.
- Advanced degree or coursework in management (MBA, MHA, MS in Management, or equivalent).
- Experience in medical leadership roles within organized medicine groups or healthcare organizations.
- Prior Medical Director experience in Medicare-related or commercial healthcare organizations.
- Familiarity with HCPCs, CPT, and ICD-10 coding and billing practices.
- Experience using GRADE methodology for literature analysis and systematic reviews.
- Experience working with physician groups, beneficiary organizations, or governmental offices.
ARC Group is committed to fostering a diverse, inclusive, and equitable workplace where every individual is valued and respected. We encourage applications from all qualified individuals, and we are dedicated to providing equal employment opportunities and accommodations during the recruitment process. Our team takes pride in connecting talented professionals with meaningful opportunities nationwide, supporting both clients and candidates with integrity and a shared desire for success.
ARC Group is an Equal Opportunity Employer. We encourage applications from all qualified individuals regardless of race, ethnicity, religion, gender identity, sexual orientation, age, disability, or any other protected status. If you require accommodations during the recruitment process, please let us know.