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 review
• medical necessity determinations
• policy/protocol development
• interdisciplinary clinical leadership
• provider education
• written, defensible clinical decision support

PM&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 judgment
• Provide clinical guidance to internal teams involved in medical review and appeals
• Support defensible written analyses for denials and appeals processes, including position paper development
• Lead or contribute to coverage determinations and policy guidance based on clinical evidence and regulatory requirements
• Evaluate evidence related to new technologies, services, and medical necessity questions
• Collaborate with multidisciplinary teams across clinical, operational, and regulatory functions
• Support program integrity efforts related to inappropriate billing, utilization, and compliance concerns
• Provide provider education and internal clinical education on policy and medical necessity topics
• Partner with CMS and other stakeholders as needed on policy and operational alignment
• Participate in quality and consistency initiatives, including clinical review decision consistency efforts

Who 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 credibility
• Physician leadership experience (Medical Director or comparable)
• Experience in inpatient rehab, post-acute, utilization-focused, payer, or claims-related settings
• Comfort reviewing records and making evidence-based determinations
• Experience developing, revising, or overseeing clinical policies, protocols, or guidelines
• Strong written communication skills for clear, defensible decision support
• Ability to educate providers and collaborate across clinical and non-clinical teams
• Interest in Medicare policy, coverage, and complex regulatory decision environments

Required qualifications:

• MD or DO degree from an accredited medical school
• Minimum of 3 years of clinical practice experience as an attending physician
• Current, active, valid, unrestricted license to practice medicine in at least one U.S. state or territory
• Board-certified MD or DO in a specialty recognized by the American Board of Medical Specialties for at least 3 years
• Eligible for licensure within the assigned jurisdiction
• Extensive knowledge of the Medicare program, particularly coverage and payment rules
• Experience 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/guidelines
• Experience evaluating clinical evidence and developing evidence-based medical necessity standards within the Medicare fee-for-service benefit structure
• Ability to support evidence-based policy decision-making in the Medicare population
• Basic understanding of medical coding conventions
• Ability to collaborate effectively with clinical and non-clinical teams
• Strong communication and public speaking skills, including provider education
• Computer literacy (word processing, spreadsheets, presentations, virtual meeting applications)

Strongly preferred qualifications

• PM&R, Internal Medicine, Oncology, Radiology, Ophthalmology, or Infectious Diseases background
• 5+ years of clinical practice experience
• Medical Director experience in a Medicare-related or commercial healthcare organization
• Coding and billing experience using HCPCS, CPT, and ICD-10
• Experience with medical review, denials, appeals, and policy support work
• Experience with evidence appraisal methods, literature review, or systematic reviews (including GRADE methodology)
• Leadership experience in organized medicine groups, specialty societies, or similar committees
• MBA, MHA, MS in Management, or formal coursework in medical systems management
• Experience working with physician groups, beneficiary organizations, and/or congressional offices

Work environment and scope:

This role includes a mix of:

• daily assigned deliverables
• complex claim-by-claim reviews
• written appeals support and position paperwork
• longer-term coverage determination and policy projects
• collaboration with federal and interdisciplinary stakeholders
• provider and internal clinical education

There 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