Position is eligible for Remote/Work from Home Opportunity*

Department: Medical Policy

Telecommuting: Yes

Paygrade: E21

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Job Title

ADLT Contract Medical Director

Job Summary

The Advanced Diagnostic laboratory Testing (ADLT) (Molecular Pathologist) Contract Medical Director (CMD) assures clinical appropriateness and standard of care for all Medicare Administrative Contractor (MAC) activities and processes, within the boundaries of federal law, Medicare regulation, medical ethics, and Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCDs), and explains, teaches, and represents these criteria, activities, and processes to all stakeholders, as appropriate.

Essential Functions

Key Duties/Responsibilities/Accountabilities

Leads a clinical program outreach related to ADLT to the practitioner, provider, supplier, and beneficiary communities.
Develops collaborative ADLT Local Coverage Determinations (LCDs), completes LCD reconsiderations, and participates in LCD challenges as required by contract.
Develops policy related articles, provides claims processing guidance, and facilitates national and local edits.
Collaborates closely with other Noridian Medical Policy staff, CMDs at other Medicare Contractors (e.g., other MACs, Unified Program Integrity Contractors (UPICs), Recovery Audit Contracts (RACs), Qualified Independent Contractors (QICs), etc.) and with CMS.
Provides guidance and medical advice for product or service-related activities, as required by contract.
Provides input and guidance to Medical Review strategies and determinations and broadly to staff training and coordination as needed.
Provides input, guidance, and participation for appeals, and Administrative Law Judge (ALJ) hearings.
Leads or participates in meetings/conferences/hearings with CMS, other MAC and CMS contractors, providers, Contractor Advisory Committees, Office of the Inspector General (OIG), US Attorneys, Food & Drug Administration (FDA), Office of Medicare Hearings and Appeals, congressional staff, and other stakeholders.
Leads or participates in initiatives to reduce Medicare FFS improper payments, as measured by Comprehensive Error Rate Testing (CERT) error rates.
Supervises and coordinates assigned staff including managing performance, developing staff, and providing oversight and direction.
Provides mentoring and input on career development and evaluation for Noridian staff.
Participates in process improvement across the organization. Contributes to the development of company policies involving clinical, safety, and related issues.
Supports and participates in the recruitment process for department positions.
Contributes to vision and strategy/direction initiatives that impact the organization/department.
Develops, reviews, and revises protocols, case reports, forms, training materials, project tools, and plan designs.
Participates in risk assessment, safety monitoring, feasibility discussions relating to specific project.

Non-Essential Duties And Functions

Other duties as assigned.

Minimum Qualifications

Doctorate degree in medicine (MD), or Doctor of Osteopathy (DO)
3 years' experience as a Medicare provider with no restrictions, suspensions, or revocations
Prior or current clinical practice as an attending physician
Board certified in clinical pathology and molecular genetic pathology
Unrestricted license to practice medicine or osteopathy in any U.S. state or territory, never suspended or revoked in any state or territory
Current or prior Drug Enforcement Administration licensure without restrictions, suspensions, or revocations
Experience in clinical administration and the overview of benefits administration and utilization review
Expertise in next-generation sequencing, genomics, clinical trials, and digital pathology
Fluency in use of Microsoft Word, Excel and PowerPoint
Knowledge of clinical issues related to CMS
Strong interpersonal and clinical skills
Ability to teach and train others and effectively work with multiple and varied stakeholders

Preferred Qualifications

Above requirements and the following:

Board certified for at least three years, and continued maintenance of ABMS Molecular Pathology certification
Experience working with physician groups, beneficiary organizations, and congressional offices.
Experience in coordinating the responses to Medicare benefits determinations, utilization adjudication, appeals, and hearings at all levels
Extensive working experience with physician groups, clinical laboratories, CMS staff and other Medicare contractors
Extensive knowledge of the Medicare program, particularly the coverage and payment rules
Detailed working knowledge of CMS National Coverage Assessments and Determinations and Medicare and related federal legislation and regulations
Detailed working knowledge of MAC Local Coverage Determinations (LCDs) and policy articles
Work 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.
Working knowledge of appeals processes and requirements, including re-openings, reconsiderations, and Administrative Law Judge hearings with detailed experience and federal court or administrative hearing experience

Environment and Cognitive/Physical Demands

Office Environment
Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve
Requires prolonged sitting and telephone use
Requires the use of office equipment such as computer terminals, telephones, copiers and printers
Infrequent lifting to 15 pounds
Infrequent stooping
Periodic travel

Segregation of Duties

Every employee is responsible to perform their duties and responsibilities in accordance with Noridian values, policies and procedures, including but not limited to: Segregation of Duties Principles, HIPAA, Security and Privacy, CMS requirements, the Noridian Compliance Program and any other applicable laws, rules and regulations.

Statement Of Other Duties

This document describes the essential functions, requirements, and responsibilities of this job, and is not intended to be a complete list of all tasks and functions. Employees may be requested to perform job related tasks other than those specifically listed in this description and may be required to perform any task requested by the supervisor or management.

Total Rewards Package

Health, Dental and Vision Insurance, Voluntary Insurance Plans, Health Savings and Flexible Spending Accounts, 401k and Company Match, Company-paid Life Insurance, Education Assistance Program, Paid Sick Leave, Paid Holidays, Increasing PTO Accrual Plan, Medical/Parental/Disability Leave, Workers Compensation, Retiree Benefits, Severance Package, Employee Assistance Program, Financial and Health Wellness Benefits, Casual Dress, Open Office Setting, and Online Learning System.

CMS Access Compliance and Regulation Contingency Statement

Some positions require compliance with (i) federal, and agency specific regulations and related clauses included in Noridian's prime contracts with the Government, (ii) background checks, and (iii) eligibility for a government-issued identification card.

Equal Employment Opportunity

Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities as well as Sexual Orientation or Gender Identity.

Other Information

Below is the salary range for potential new hires:

Salary Range: $221,218.39 - $365,405.38

Other Compensation: Self-Managed PTO, Incentive Plan

This job will be closed 06/30/2023 at 8:00 AM CST. No further applications will be considered.

Noridian Healthcare Solutions, LLC

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