Medical Director Federal Health (CMS)

At Commence were the start of a new age of data-centric transformation elevating health outcomes and powering better more efficient process 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.

The Medical Director is the senior physician on a CMS program and the final clinical authority for complex medical review determinations. The CMD provides direct oversight of clinical review quality participates in Discussion and Education (D&E) sessions when providers escalate disputes to the physician level and represents CMS at Administrative Law Judge (ALJ) hearings to defend review decisions. The CMD works closely with the Project Manager clinical review staff and legal counsel to ensure the integrity and defensibility of all program medical determinations.

Essential Duties and 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.

*Commence headquarters are in Virginia Beach VA however we are open to remote candidates in the following states: AZ AR DE FL GA IL IN KS KY MA MD MI MS MO MT NC NE NV NY OH OK PA SC TN TX VA DC WI and WV*

Work Environment/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 a 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.

Commence is an equal employment opportunity for 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.

is committed to providing equal employment opportunities to all applicants including individuals with disabilities. If you require reasonable accommodation to participate in the application process due to a disability please contact Human Resources at or .

Please note that unless you are requesting an accommodation all applications must be submitted through our online application system.