Medical Director; PM&R

Job Title: Medicare Contractor Medical Director (CMD) –
Physical Medicine & Rehabilitation (PM&R Focus)

Employment Type: Full-Time

Work Environment: Remote with limited travel (approximately 3–4 weeks per year, based on business needs)

The Medicare Contractor Medical Director (CMD) provides senior-level medical leadership and clinical decision-making in support of the Medicare program and serves as a liaison between healthcare stakeholders and the Centers for Medicare and Medicaid Services (CMS).

This role plays a critical part in developing Local Coverage Determinations (LCDs), ensuring compliance with Medicare policies, reviewing complex medical claims, and advancing evidence-based healthcare practices. The position is ideally suited for a board-certified PM&R physician with strong clinical expertise, policy acumen, and a passion for provider education and quality improvement.

• Provide leadership in clinical program outreach to practitioners, providers, suppliers, and beneficiaries.
• Guide and support clinical staff in provider education initiatives and clinical guideline development.
• Maintain current knowledge of medical practice standards and emerging healthcare technologies.
• Serve as a subject matter expert in medical and clinical issues relevant to the Medicare population.
• Provide clinical consultation to internal teams (medical review, appeals) and external stakeholders.
• Apply scientific literature review and claims data analytics to inform medical policy and identify high-risk or problem areas.

• Collaborate with CMS and other Medicare contractors to develop and update medical policies and coverage articles in accordance with clinical evidence and regulatory requirements.
• Work with multidisciplinary teams to improve operational processes and ensure compliance with CMS directives.
• Liaise with CMS staff, medical societies, and other stakeholders to align objectives and address emerging issues.
• Represent the organization at CMS meetings and professional conferences.
• Strengthen quality improvement initiatives with emphasis on decision consistency and clinical staff education, including oversight of Inter-Reviewer Reliability (IRR) activities

• Support program integrity efforts by identifying trends in inappropriate billing or noncompliance.
• Ensure correct application of Medicare regulations, National Coverage Determinations (NCDs), LCDs, and clinical guidelines.
• Lead all phases of LCD development, including creation, revision, retirement, education, and policy decision-making.
• Collaborate with investigative teams and law enforcement when required.

• Oversee medical review activities to ensure accurate and consistent claim determinations (pre- and post-payment).
• Develop and implement Medical Review Quality Assurance programs and internal review guidelines.
• Review complex or high-level appeals and provide expert guidance on Medicare policy application.
• Support the appeals process through position paper development and participation in administrative hearings (e.g., ALJ hearings).

• Provide leadership within the provider community, including engagement with hospital and specialty associations.
• Educate providers individually and in group settings on medical policies and identified compliance issues.
• Maintain strong professional relationships with internal teams and external partners.

• MD or DO degree from an accredited medical school.
• Minimum of three (3) years of clinical practice experience as an attending physician.
• Extensive knowledge of the Medicare program, including coverage and payment rules.
• Experience in health insurance, utilization review, or healthcare claims processing involving development of medical necessity or coverage policies.
• Demonstrated ability to evaluate clinical evidence and develop evidence-based medical necessity standards within the Medicare fee‑for‑service structure.
• Basic understanding of medical coding conventions.
• Strong communication skills with the ability to…