Medical Director (Medicare)

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Medical Director (Medicare) based in the United States.

This role provides medical leadership and expertise supporting Medicare claims review, coverage decisions, and healthcare policy initiatives. You will leverage your clinical background to guide complex medical determinations and improve the accuracy of healthcare program operations. The position combines clinical judgment, regulatory knowledge, stakeholder engagement, and strategic advisory responsibilities. You will collaborate with healthcare professionals, government stakeholders, and internal teams to address national coverage and payment challenges. The ideal candidate will bring strong Medicare expertise, excellent communication skills, and experience applying medical standards in a policy-driven environment. This is an opportunity to influence healthcare quality, compliance, and decision-making at a national level.

Accountabilities:: The Medical Director will provide clinical insight, regulatory guidance, and medical expertise to support Medicare claims review processes and healthcare program initiatives. This role requires collaboration with medical professionals, stakeholders, and leadership teams to ensure accurate, compliant, and effective healthcare decisions.

Provide medical expertise and oversight for Medicare claims review determinations, including complex medical necessity and coverage evaluations.

Review and interpret medical documentation, clinical guidelines, CMS policies, regulations, and coding resources to support accurate decisions.

Serve as a medical representative and spokesperson when engaging with medical societies, physician groups, stakeholders, and industry organizations.

Maintain current knowledge of medical practice standards, healthcare technologies, Medicare requirements, and evolving regulatory guidance.

Support the development, review, and improvement of contractor policies, written guidelines, and operational procedures.

Collaborate with leadership teams to identify Medicare payment vulnerabilities, improper payment drivers, and opportunities for program improvement.

Provide input on proposed policy changes, payment methodologies, and national healthcare coverage issues.

Coordinate educational sessions and knowledge-sharing activities for medical review staff and healthcare professionals.

Work with external partners and healthcare organizations to align policy development and share best practices.

Prepare reports, documentation, and updates according to established quality and compliance requirements.

Maintain adherence to CMS procedures, quality standards, and contractual obligations while supporting assigned projects.

Requirements:

The ideal candidate will be a board-certified physician with significant clinical experience and deep knowledge of Medicare policies, healthcare regulations, and medical review processes. Strong analytical abilities, communication skills, and experience working with healthcare organizations are essential for success in this role.

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree with active medical licensure.

Board certification and at least four years of professional medical practice experience.

Extensive knowledge of Medicare programs, including coverage rules, payment policies, and regulatory requirements.

No current or previous adverse actions from Medicare, Medicaid, federal or state programs, medical insurance programs, or medical licensing boards.

Experience working in healthcare insurance, utilization review, claims processing, or similar healthcare policy environments.

Experience developing medical necessity guidelines, coverage policies, or clinical review standards preferred.

Strong understanding of medical documentation, coding guidelines, and healthcare compliance requirements.

Excellent communication, collaboration, and decision-making skills with the ability to work effectively across diverse stakeholder groups.

Experience presenting to physician organizations, beneficiary groups, government stakeholders, or healthcare industry audiences preferred.

Proficiency with technology tools including Microsoft Word, Excel, SharePoint, and web-based meeting platforms.

Ability to operate effectively in a remote, team-oriented environment.

Benefits:

Competitive compensation package based on experience, qualifications, and role alignment.

Fully remote work opportunity within the United States.

Opportunity to influence healthcare programs and Medicare operations on a national scale.

Collaborative environment working with healthcare professionals and industry stakeholders.

Professional growth opportunities through impactful healthcare initiatives.

Access to technology tools and resources needed to support remote work.

How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best!  Why Apply Through Jobgether?    Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.     #LI-CL1