Medical Director - Prior Authorization Automation

Genzeon, an AI and automation company with deep engineering and data expertise, dedicated to serving the healthcare and retail industries. Our platform solutions including HIP One, CompliancePro Solutions, and Patient Engagement Solutions empower organizations to scale innovation and transform outcomes.

Genzeon is a global community of innovators and problem-solvers, with a culture built on inclusion, flexibility, and purpose-driven work. With four global delivery centers, we support providers, payers, Healthtech, and retail organizations worldwide.

Genzeon has an exciting opening for Medical Director - Prior Authorization Automation to join our dynamic team.

Medical Director - Prior Authorization Automation

Remote

Part-Time

Medical Director - Prior Authorization Automation

Model Participant Organization

Position Overview

We are seeking an experienced Medical Director to lead our award-winning Prior Authorization automation program focused on medical necessity decision-making. This role will oversee the clinical governance and implementation of automated prior authorization processes for multiple specialized medical services, ensuring compliance with Medicare coverage determinations while improving efficiency and patient access to care.

Key Responsibilities

Clinical Leadership & Governance

• Provide clinical oversight for automated prior authorization algorithms and decision-support systems
• Establish and maintain clinical criteria for medical necessity determinations aligned with NCDs and LCDs
• Chair the Clinical Advisory Committee overseeing automation protocols
• Ensure clinical integrity and appropriateness of automated determinations
• Develop and update clinical policies for covered services

Program Management

• Lead implementation of prior authorization automation across multiple service lines
• Collaborate with technology teams to refine clinical decision algorithms
• Monitor program performance metrics including approval rates, turnaround times, and appeal outcomes
• Interface with CMS and Medicare Administrative Contractors (MACs) on coverage policies
• Ensure compliance with CMS WISeR Model requirements and quality measures

Specialty Service Oversight

Provide clinical leadership for automated prior authorization across the following services:

Pain Management & Interventional Services:

• Induced Lesions of Nerve Tracts (NCD 160.1)
• Epidural Steroid Injections
• Percutaneous Image-Guided Lumbar Decompression (NCD 150.13)
• Electrical Nerve Stimulators (NCD 160.7)

Surgical Services:

• Cervical Fusion (L39741, L39762, L39793)
• Percutaneous Vertebral Augmentation (L34106, L38201, L35130)
• Arthroscopic Lavage and Debridement (NCD 150.9)
• Phrenic Nerve Stimulator (NCD 160.19)
• Sacral Nerve Stimulation (NCD 230.18)

Wound Care & Specialized Services:

• Bioengineered Skin Substitutes (L35041)
• Cellular/Tissue-Based Products (L36690)

Stakeholder Engagement

• Serve as clinical liaison with specialty providers including orthopedic surgeons, neurosurgeons, interventional pain specialists, and other relevant specialties
• Lead provider education initiatives on prior authorization requirements
• Collaborate with health plans and provider networks
• Present program outcomes to executive leadership and board

Quality & Compliance

• Ensure all automated determinations comply with Medicare coverage policies
• Oversee clinical appeals and peer review processes
• Monitor and address quality concerns or adverse determinations
• Maintain HIPAA compliance and patient confidentiality standards
• Support FISMA authorization requirements for healthcare IT systems

Required Qualifications

Education & Licensure

• MD or DO degree from accredited medical school
• Active, unrestricted medical license
• Board certification in relevant specialty (Pain Medicine, Orthopedic Surgery, Neurosurgery, PM&R, or related field preferred)
• Current DEA registration

Experience

• Minimum 7-10 years clinical practice experience
• 3+ years in medical director or clinical leadership role
• Prior experience with utilization management and prior authorization processes
• Demonstrated experience with Medicare coverage policies and NCDs/LCDs
• Experience with healthcare technology implementation preferred

Technical Knowledge

• Strong understanding of Medicare coverage determination processes
• Familiarity with X12 transaction standards and esMD systems
• Knowledge of automated clinical decision support systems
• Understanding of healthcare data interoperability standards

Preferred Qualifications

• Experience with CMS innovation models or value-based care programs
• Background in clinical informatics or healthcare IT
• Published research in relevant clinical areas
• Experience with machine learning applications in healthcare
• Leadership experience in multi-specialty clinical environments

Key Competencies

• Clinical Excellence: Deep understanding of evidence-based medicine and clinical guidelines
• Leadership: Ability to lead cross-functional teams and drive organizational change
• Communication: Excellent verbal and written communication with diverse stakeholders
• Analytical Thinking: Ability to analyze complex clinical data and program metrics
• Innovation: Forward-thinking approach to healthcare automation and efficiency
• Regulatory Acumen: Strong understanding of healthcare compliance requirements

Compensation & Benefits

• Competitive salary commensurate with experience
• Performance-based incentive compensation
• Comprehensive health, dental, and vision insurance
• Retirement plan with employer matching
• CME allowance and professional development opportunities
• Flexible work arrangements
• Malpractice insurance coverage