• Medical Director UPIC MW

    Job ID 2018-2252
    Job Locations
    US-OH-Grove City | US-Remote
    Healthcare / Biotechnology
    Regular Full-Time
  • Overview

    NCI is a leading provider of enterprise solutions and services to U.S. defense, intelligence, health and civilian government agencies. Coupled with a refined focus on strategic partnerships, we are successfully bridging the gap between commercial best practices and mission-critical government processes. Core competencies include:

    • Artificial intelligence
    • Agile digital transformation
    • Advanced analytics
    • Hyperconverged infrastructure solutions
    • Cyber security and information assurance
    • Fraud, waste and abuse
    • Engineering and logistics


    NCI has been designated a 2018 Military Friendly Employer by MilitaryFriendly.com 


    Headquartered in Reston, Virginia, NCI has approximately 2,000 employees operating at more than 100 locations worldwide.


    NCI: As the Medical Director (Medical Director) at AdvanceMed, you will serve as a readily available source of medical information to provide guidance to medical review staff and to provide the clinical expertise and judgment to effectively focus staff on areas of potential Medicare and Medicaid fraud and abuse.  In assuming this position, you will be a critical contributor to meeting NCI AdvanceMed's mission: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.  


    Highlights of Responsibilities:

    • Interacts with the medical community, educating providers individually or as a group regarding identified problems
    • Keeps abreast of medical practice and technology changes that may result in improper billing or program abuse
    • Briefs and directs personnel on the correct application of Medicare policy during Medicare and Medicaid claims review
    • Provides medical insight and expertise for Medicare and Medicaid claims review decisions and national coverage payment issues
    • Interacts with Medical Directors at other Centers for Medicare/Medicaid Services (CMS) contractors to share information and coordinates contractor policy development when appropriate
    • Maintains working knowledge of medical practice standards, guidelines and related technology
    • Assists with development of contractor policy, including necessary updating of policies and the development of written guidelines used by the Task order
    • Provides medical insight and expertise for the claims reviews conducted by specialty physicians and medical review specialists
    • Presents medical specialty education sessions as needed
    • Provides expert testimony as required
    • Ensures compliance with Program Integrity Manual (PIM) guidelines and CMS directives concerning Medical Review
    • Performs other duties as assigned that contributes to Task order goals and objectives





    • Board certified Doctor of Medicine or a Doctor of Osteopathy in a specialty recognized by the American Board of Medical Specialties.
    • Must have a minimum of 3 Years practicing Medicine as a board certified doctor of medicine or osteopathy.
    • Must have an active valid and unrestricted license.
    • Prior experience testifying and making claims review decisions based on regulations.
    • Proficient in conducting internet research and ability to navigate through AdvanceMed's internal case tracking system.
    • Ability to teach and articualte findings to Medical Review staff.
    • Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
    • Must have no conflict of interest (COI) as defined in § 1154(b) (1) of the Social Security Act.
    • Must have and maintain a valid driver’s license for the associate’s state of residence - travel expectation is 25%.

    Preferred Education and Experience:

    • Prior work experience in the health insurance industry, a utilization review firm, or another health care processing organization in a role that involved developing coverage or medical necessity policies or guidelines is preferred
    • Prior experience with Medicare and Medicaid claims review decisions.
    • Prior experience writing policy.
    • Prior expeirence with PIM (Program Integrity Manual) guidelines.
    • Prior public relations experience such as working with physician groups, beneficiary organizations, and/or congressional offices is preferred




    This position requires the ability to perform the below essential functions:

    • Sitting for long periods
    • Standing for long periods
    • Ambulate throughout an office
    • Ambulate between several buildings
    • Stoop, kneel, crouch, or crawl as required
    • Repeatedly lift and carry weight up to 20 pounds
    • Travel by land or air transportation 25%


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