Medical Director (Federal Health)

TL;DR

Medical Director (Federal Health): Serving as the final clinical authority for complex medical review determinations within a CMS program with an accent on clinical quality assurance, policy interpretation, and legal defense. Focus on representing the program at Administrative Law Judge (ALJ) hearings, resolving provider disputes, and ensuring the integrity of medical determinations under Medicare coverage policies.

Location: Remote, must be based in 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, or WV

Company

hirify.global is a data-centric healthcare technology company providing value-based solutions to improve health outcomes and operational efficiency.

What you will do

• Act as the final clinical authority for complex, disputed, or escalated medical review determinations.
• Represent the program at Administrative Law Judge (ALJ) hearings, including testifying and defending clinical review decisions.
• Participate in Discussion and Education (D&E) sessions with providers regarding escalated disputes.
• Provide clinical oversight and quality assurance to ensure determinations are consistent and defensible.
• Engage with CMS on policy interpretation, issue resolution, and emerging coverage questions.
• Collaborate with project management and clinical staff to support continuous quality improvement.

Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) with board certification in a relevant specialty.
• Active, unrestricted medical license in the United States.
• Minimum 3 years of active medical practice experience post-residency.
• Background in health insurance, utilization review, or healthcare claims processing.
• Familiarity with medical necessity criteria and coverage determination standards.
• Must be based in one of the approved 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, or WV.

Nice to have

• Prior experience as a Contractor Medical Director at a CMS review contractor.
• In-depth knowledge of Medicare coverage policies, NCDs, LCDs, and IOM 100-8 guidance.
• Experience leading ALJ hearing representation and presenting clinical evidence.
• Multi-state medical licensure.

Culture & Benefits

• Purpose-driven culture focused on improving patient care and health outcomes.
• Emphasis on straightforward communication and clinical domain expertise.
• Remote work environment with climate-controlled home office requirements.
• Equal employment opportunity employer committed to merit-based personnel processes.