Palmetto GBA

The Medicare Medical Director provides administrative oversight to the medical staff, analyzes utilization data, researches new medical procedures, and acts as a resource on medical policies, including writing and revising them. Responsibilities also include supporting operations via case review, developing claim adjudication criteria, and educating staff and the medical community on policy administration.

This role ensures adherence to Local Coverage Determination (LCD) process contract instructions by developing and maintaining educational tools to help providers reduce non-covered service claims and lower the claims payment error rate. The coordinator will provide clinical expertise and judgment to develop and maintain LCDs, educate internal and external customers, and communicate coding and reimbursement guidelines for compliance.

The role involves conducting internal and external audits covering financial, compliance, and operational aspects, including evaluating internal controls and identifying business risks across various corporate entities. Responsibilities also include drafting recommendations, writing comprehensive audit reports for executive management, and testing corrective actions.

This role provides supervision and direction for the statistical reporting function and data analysis supporting clinical reporting, while maintaining high standards of integrity and confidentiality regarding member/customer privacy. Key duties involve monitoring reporting adherence, setting functional direction, performing clinical trend analysis, developing reports, and collaborating across areas to improve outcomes and reduce expenses.

As a member of the senior management team, the Medical Director provides administrative oversight to the medical staff, analyzes utilization data, researches new medical procedures, and acts as a resource on medical policy issues. Responsibilities also include supporting operations through case review, developing claim adjudication criteria, and educating staff and the medical community on policy administration.

This role is responsible for supervising the receipt, review, and settlement of the Medicare cost report, ensuring strict adherence to all Centers for Medicare and Medicaid Services (CMS) requirements. Key duties include performing supervisory review of all team audit work papers and cost report acceptances, planning/monitoring team work, and assisting in staff development through training.

The Associate Medical Director DME provides administrative oversight to the medical staff, analyzes utilization data, researches new medical technology, and serves as a resource on medical device coding and DMEPOS policies for various stakeholders. This role also involves overseeing coding integrity efforts and writing/revising coding advisory articles related to Medicare policy and procedure.