Medical Director – CMS Medical Review (RVC)

The Medical Director serves as the senior clinical authority for the CMS Review and Validation Contractor (RVC) program. This role provides leadership and oversight for all medical review functions, ensuring compliance, clinical accuracy, and alignment with Medicare coverage and payment policy. The CMD must be available to CMS between 8:00 AM and 4:30 PM ET, Monday–Friday, and must be fully dedicated to the RVC contract.

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Key Responsibilities

• Oversee all aspects of medical review, validation activities, and quality assurance.

• Direct clinical personnel on correct application of Medicare policy during the validation process.

• Participate in CMS discussions, trainings, and policy interpretation sessions.

• Oversee training and education of RVC medical reviewers.

• Provide expert guidance on LCDs, NCDs, Medicare manuals, and all applicable medical policies.

• Serve as an expert resource during complex or questionable claim reviews.

• Monitor changes in medical practices and technology that may affect billing or improper payment risks.

• Recommend updates to LCDs, NCDs, system edits, and corrective actions based on RAC-identified vulnerabilities.

• Participate in CMS/RVC clinical workgroups and presentations as needed.

• Maintain compliance with conflict-of-interest reporting requirements.

• Ensure non-medical staff do not perform or oversee tasks requiring clinical judgment.

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Required Qualifications

Experience

• Minimum 3 years of clinical practice as a board-certified physician with no Medicare sanctions or exclusions.

• Minimum 2 years of experience in:

  • Health insurance

  • Utilization review

  • Claims processing

  • Medicare or federal healthcare program administration

• Extensive knowledge of Medicare coverage, billing, and payment rules.

• Experience working with physician groups, beneficiary organizations, and/or congressional offices preferred.

• Working knowledge of the CMS Fee-for-Service (FFS) Recovery Audit Program.

Education & Licensure

• Doctor of Medicine (MD) or Doctor of Osteopathy (DO), board-certified.

• Active, unrestricted license to practice medicine in a U.S. state or territory (verified annually).

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Core Competencies

• Expert understanding of Medicare policy, LCDs, NCDs, and clinical review requirements.

• Strong clinical judgment and analytical skills.

• Ability to lead, mentor, and direct multidisciplinary review teams.

• Excellent communication and documentation skills.

• Professional integrity and ability to make independent, impartial clinical determinations.

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Work Requirements

• Full-time, fully dedicated role; may not perform work for other Medicare or non-Medicare contracts without CMS approval.

• Availability required between 8:00 AM and 4:30 PM ET, Monday–Friday.