Job Description

Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.

*This position is located Remote Anywhere US*

*This position requires a credit check*

Position Purpose:

Provides physician leadership and quality oversight for the task order or project.

Essential Responsibilities:

• Direct Leadership over Physician Reviewers. Responsible for productivity, production, and quality of the decisions for second level appeals related to Medicare Part C (e.g., Medicare Advantage Organizations, Medicare cost plans, health care prepayment plans, and Programs of All-inclusive Care for the Elderly (PACE)).
• Provide leadership in support of accurate and timely processing of higher level appeals (reconsiderations) related to Medicare Part C.
• Provides executive leadership to Physician Reviewers and oversees their productivity, production, and decision letter quality.
• Oversees, directs and monitors quality and continuous improvement of the quality assurance program.
• Performs quality audits of physician reviews.
• Ability to communicate health care appeal issues to various stakeholders
• Motivate and align staff, processes, and tools to meet contract requirements, government regulations, and provide good customer satisfaction.
• Develops and monitors reports and data analysis to identify root causes of items that should be improved to improve the overall medical program.

Minimum Qualifications

Education

• Graduate of an accredited medical school

License and Certification

• Active State license to practice medicine

• Board certification

Experience

• Ten (10) years clinical

• Five (5) years demonstrated and progressively responsible medical managerial or leadership role
• At least 5 years of direct Medicare experience working as a medical director, physician reviewer, or other senior medical position within an organization that provides services under Medicare Part C (e.g., Medicare Advantage Organizations, Medicare cost plans, health care prepayment plans, and Programs of All-inclusive Care for the Elderly (PACE)). (Per Contract Requirements)
• Three (3) years of experience as a physician reviewer on Medicare Part C appeals (Per Contract Requirements)

• Extensive knowledge of the Medicare program, including the coverage and payment rules of Medicare Part C
• Knowledge of Medicare regulations, claims administration, and medical review processes
• No federal or state sanctions as would appear on reporting from the National Practitioner Data Bank (NPDB)

• Currently have or have had direct patient care within the last three years

• Experience interpreting and implementing CMS guidelines and regulatory updates related to Medicare Advantage, preferred

Benefits

C2C offers an excellent benefits package, including:

• Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
• Section 125 plan
• 401K
• Competitive salary
• License/credentials reimbursement
• Tuition Reimbursement

EOE Vet/Disability