Clinical Medical Director

Description

At Commence, we’re 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.

Requirements

We are seeking a board-certified physician to serve as Clinical Medical Director in support of CMS Healthcare Program. In this role, you will provide clinical leadership and medical expertise to support the federal independent dispute resolution (IDR) process ensuring that dispute resolution decisions are grounded in sound clinical standards, coding guidance, and medical necessity criteria.

This is a high-impact, policy-adjacent role combining clinical expertise with federal health program operations. The Clinical Medical Director will work closely with program management, legal, and analytical staff to support accurate, compliant, and defensible dispute resolution outcomes.

Key Responsibilities

• Provide clinical oversight and medical subject matter expertise across program operations
• Review and adjudicate complex medical necessity, coding, and billing disputes involving out-of-network claims
• Develop and maintain clinical review protocols, decision frameworks, and quality standards
• Serve as the clinical authority on provider billing practices, medical coding (CPT, ICD-10), and insurance coverage determinations
• Advise program and legal staff on clinical aspects of IDR cases, including surprise billing policy interpretation
• Support development and delivery of training for clinical reviewers and case management staff
• Interface with CMS clinical policy staff as needed on program-level clinical questions
• Ensure clinical decisions are consistent with current guidelines, CMS policy, and applicable law (No Surprises Act, ERISA, state surprise billing laws)

Minimum Qualifications

• M.D. or D.O. degree required; board-certified in a relevant specialty
• Active, unrestricted medical license; multi-state licensure a plus
• 5+ years of clinical practice experience post-residency
• 3+ years in a medical director, utilization management, or independent medical review role
• Strong working knowledge of CPT coding, medical billing, and insurance reimbursement processes
• Familiarity with utilization management criteria (InterQual, MCG/Milliman) and clinical appeals
• Experience with federal health programs (Medicare, Medicaid, or CHIP) preferred
• Excellent written and verbal communication; ability to produce clear, defensible clinical rationale documentation
• Must be eligible for CMS Public Trust (MBI) clearance

Preferred Qualifications

• Direct experience with surprise billing, IDR, IRO, or IME (Independent Medical Examination) programs
• Background with CMS, health insurance exchange operations, or ACA regulatory environment
• Peer review or Independent Review Organization (IRO) experience
• Health law, compliance, or healthcare policy background (J.D. or MPH a plus)
• Commence' headquarters are in Virgina 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

Employment Equity

Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require a reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or [email protected]. Please note that unless you are requesting accommodation, all applications must be submitted through our online application system.