Adlt Contract Medical Director

*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

• Provides input, guidance, and participation for appeals, and Administrative Law Judge (ALJ) hearings.
• Develops policy related articles, provides claims processing guidance, and facilitates national and local edits.
• Participates in risk assessment, safety monitoring, feasibility discussions relating to specific project.
• 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.
• Participates in process improvement across the organization. Contributes to the development of company policies involving clinical, safety, and related issues.
• 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.
• Provides mentoring and input on career development and evaluation for Noridian staff.
• Develops collaborative ADLT Local Coverage Determinations (LCDs), completes LCD reconsiderations, and participates in LCD challenges as required by contract.
• Leads or participates in initiatives to reduce Medicare FFS improper payments, as measured by Comprehensive Error Rate Testing (CERT) error rates.
• Develops, reviews, and revises protocols, case reports, forms, training materials, project tools, and plan designs.
• Supports and participates in the recruitment process for department positions.
• Leads a clinical program outreach related to ADLT to the practitioner, provider, supplier, and beneficiary communities.
• Contributes to vision and strategy/direction initiatives that impact the organization/department.
• 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.
• Supervises and coordinates assigned staff including managing performance, developing staff, and providing oversight and direction.

Non-Essential Duties and Functions

• Other duties as assigned.

Minimum Qualifications

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

Preferred Qualifications

Above requirements and the following:

• Extensive working experience with physician groups, clinical laboratories, CMS staff and other Medicare contractors
• Detailed working knowledge of CMS National Coverage Assessments and Determinations and Medicare and related federal legislation and regulations
• Board certified for at least three years, and continued maintenance of ABMS Molecular Pathology certification
• Experience in coordinating the responses to Medicare benefits determinations, utilization adjudication, appeals, and hearings at all levels
• 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.
• Experience working with physician groups, beneficiary organizations, and congressional offices.
• Detailed working knowledge of MAC Local Coverage Determinations (LCDs) and policy articles
• Extensive knowledge of the Medicare program, particularly the coverage and payment rules
• 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

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

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.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)