Clinical Medical Director

Commence; Atlanta (GA); Híbrido; USD 200 000 - 280 000; Tempo integral

Resumo da oferta

Commence seeks a full-time Medical Director-level physician for a hybrid office/remote role focused on Medicare review and coverage determinations. You will lead medical review determinations, testify at ALJ hearings, and collaborate with CMS and internal teams to ensure policy compliance.

The role requires board-certified MD/DO, active US licensure, and at least 3 years of practice post-residency, with experience in health insurance or claims processing and strong CMS-directed engagement.

Qualificações

• MD/DO board-certified.
• Licensed to practice medicine in the United States; active license.
• Minimum 3 years of active medical practice post-residency.
• Background in health insurance, utilization review, or healthcare claims processing.
• Demonstrated hands-on participation in medical review activities and CMS-directed meetings.

Responsabilidades

• Serve as the final clinical authority for complex medical review determinations under the CMS program.
• Represent the program at ALJ hearings; testify and defend the clinical basis for reviews.
• Participate in D&E sessions with providers when disputes reach physician level.
• Provide clinical oversight and quality assurance across medical review and ensure defensible determinations.
• Engage with CMS on issue resolution and policy interpretation; attend CMS meetings and work groups.
• Collaborate with Project Manager, clinical reviewers, and leadership to support program performance and quality improvement.
• Maintain currency with Medicare coverage policies, NCDs, LCDs, and IOM guidance.

Conhecimentos

CMS policy

Medical oversight

ALJ hearings

Stakeholder engagement

Formação académica

MD/DO board-certified

Descrição da oferta de emprego

Overview

At Commence, we’re the start of a new age of data‑centric transformation, elevating health outcomes and powering better, more efficient processes to program and patient health. We combine quality data‑driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care.

With human‑centered, healthcare‑relevant, and value‑based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication, and clinical domain expertise, Commence cuts straight to better care.

Job Type: Full‑time

Responsibilities

• Serve as the final clinical authority for complex, disputed, or escalated medical review determinations across the CMS program.
• Represent the program at Administrative Law Judge (ALJ) hearings; testify and defend the clinical basis for review determinations. Minimum 10 ALJ appearances per month required.
• Participate in Discussion and Education (D&E) sessions with providers and their representatives when disputes are escalated to the physician level.
• Provide clinical oversight and quality assurance across the medical review function, ensuring determinations are consistent, well‑documented, and defensible under Medicare coverage policy.
• Actively engage with CMS on issue resolution, medical review policy interpretation, and emerging coverage questions; participate in CMS meetings and work groups as required.
• Collaborate with the Project Manager, clinical reviewers, and operational leadership to support program performance, staff education, and continuous quality improvement.
• Maintain currency with Medicare coverage policies, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and relevant IOM guidance (including IOM 100‑8).

Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO); board‑certified in a relevant specialty.
• Currently licensed to practice medicine in the United States; licensure must remain active and in good standing throughout employment.
• Minimum 3 years of active medical practice experience post‑residency.
• Background in health insurance, utilization review, or healthcare claims processing, including familiarity with medical necessity criteria and coverage determination standards.
• Demonstrated capacity for active, substantive engagement in medical review activities, issue resolution, and CMS‑directed meetings — this position requires consistent hands‑on participation and is not a nominal or figurehead role.

Preferred Qualifications

• Prior Contractor Medical Director or Medical Director experience at a CMS review contractor.
• In‑depth familiarity with Medicare coverage policy, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Internet‑Only Manual guidance, including IOM 100‑8.
• Experience participating in or leading ALJ hearing representation in a Medicare appeals context, including preparation of written testimony and presentation of clinical evidence.
• Multi‑state medical licensure preferred given the nationwide scope of review activities.

Work Environment and Physical Demands

The work environment and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This is an office/remote position. While performing the duties of this job, the employee regularly works in a climate‑controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch.

Equal Employment Opportunity

Commence is an equal employment opportunity employer. All personnel processes are merit‑based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law. Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require a reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306‑4920 or [e-mail]. Please note that unless you are requesting an accommodation, all applications must be submitted through our online application system.