Job Title

Medical Director, Medicare Clinical Review and Coverage Policy (PM&R/Physician)Compensation: $185,000 to $264,000 (commensurate with experience) Travel: Approximately 3 to 4 weeks per year (variable based on business need) Location/Work Model: Remote eligible in approved states/counties (telework restrictions apply)Why this role stands out: This is a physician leadership role for candidates who enjoy complex clinical reviews, evidence-based decision-making, and policy guidance work in a Medicare environment.This is a strong fit for physicians who have moved beyond direct patient care only and have experience with:utilization reviewmedical necessity determinationspolicy/protocol developmentinterdisciplinary clinical leadershipprovider educationwritten, defensible clinical decision supportPM&R and rehab physician leaders are strongly encouraged to apply, along with other board-certified physicians who bring similar review and policy experience.What you will do:You will provide medical leadership and decision support in a Medicare contractor environment, including a mix of daily case review work and longer-range policy projects.Core responsibilities:Review complex or non-standard claims where coverage is unclear or requires physician judgmentProvide clinical guidance to internal teams involved in medical review and appealsSupport defensible written analyses for denials and appeals processes, including position paper developmentLead or contribute to coverage determinations and policy guidance based on clinical evidence and regulatory requirementsEvaluate evidence related to new technologies, services, and medical necessity questionsCollaborate with multidisciplinary teams across clinical, operational, and regulatory functionsSupport program integrity efforts related to inappropriate billing, utilization, and compliance concernsProvide provider education and internal clinical education on policy and medical necessity topicsPartner with CMS and other stakeholders as needed on policy and operational alignmentParticipate in quality and consistency initiatives, including clinical review decision consistency effortsWho tends to do well in this role:Candidates who are often successful in this type of role typically have a combination of the following:Board-certified physician with strong clinical credibilityPhysician leadership experience (Medical Director or comparable)Experience in inpatient rehab, post-acute, utilization-focused, payer, or claims-related settingsComfort reviewing records and making evidence-based determinationsExperience developing, revising, or overseeing clinical policies, protocols, or guidelinesStrong written communication skills for clear, defensible decision supportAbility to educate providers and collaborate across clinical and non-clinical teamsInterest in Medicare policy, coverage, and complex regulatory decision environmentsRequired qualifications:MD or DO degree from an accredited medical schoolMinimum of 3 years of clinical practice experience as an attending physicianCurrent, active, valid, unrestricted license to practice medicine in at least one U.S. state or territoryBoard-certified MD or DO in a specialty recognized by the American Board of Medical Specialties for at least 3 yearsEligible for licensure within the assigned jurisdictionExtensive knowledge of the Medicare program, particularly coverage and payment rulesExperience in a health insurance organization, utilization review firm, or healthcare claims processing organization in a role involving the development of coverage or medical necessity policies/guidelinesExperience evaluating clinical evidence and developing evidence-based medical necessity standards within the Medicare fee-for-service benefit structureAbility to support evidence-based policy decision-making in the Medicare populationBasic understanding of medical coding conventionsAbility to collaborate effectively with clinical and non-clinical teamsStrong communication and public speaking skills, including provider educationComputer literacy (word processing, spreadsheets, presentations, virtual meeting applications)Strongly preferred qualificationsPM&R, Internal Medicine, Oncology, Radiology, Ophthalmology, or Infectious Diseases background5+ years of clinical practice experienceMedical Director experience in a Medicare-related or commercial healthcare organizationCoding and billing experience using HCPCS, CPT, and ICD-10Experience with medical review, denials, appeals, and policy support workExperience with evidence appraisal methods, literature review, or systematic reviews (including GRADE methodology)Leadership experience in organized medicine groups, specialty societies, or similar committeesMBA, MHA, MS in Management, or formal coursework in medical systems managementExperience working with physician groups, beneficiary organizations, and/or congressional officesWork environment and scope:This role includes a mix of:daily assigned deliverablescomplex claim-by-claim reviewswritten appeals support and position paperworklonger-term coverage determination and policy projectscollaboration with federal and interdisciplinary stakeholdersprovider and internal clinical educationThere is no single "typical day." The work is varied and requires strong clinical judgment, adaptability, and comfort operating in a highly collaborative regulatory environment.Travel and location notes:Travel within and outside the covered jurisdictions is expected to be needed, typically no more than 3 to 4 weeks per year.Remote hiring is subject to approved telework states/counties and internal approval requirements based on location. Ascendo is a certified minority owned staffing firm, and we welcome and celebrate diversity. Ascendo is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, parental status, military service or any other characteristic protected by federal, state or local law.Contact information Christian Kincer