VP, Clinical Policy and Risk Management (Healthcare)

Location: Remote nationwide within the United States; occasional travel to hirify.global offices for training or meetings may be required.

Company

hirify.global is a U.S. healthcare and insurance company serving Medicare and Medicaid members through insurance and healthcare services.

What you will do

• Lead clinical and operational risk management across Care Management and Utilization Management.
• Oversee a department of 7 direct reports and 250 associates, including CM/UM risk management, audit teams, and policy governance.
• Identify, assess, monitor, report, and mitigate risks affecting member care, compliance, and operations.
• Interpret and implement CMS federal and Medicaid state regulations affecting CM/UM processes.
• Support regulatory audits, remediation, litigation readiness, business continuity, and issue resolution.
• Partner with Legal, Compliance, Regulatory Affairs, and business leaders on emerging regulatory and legislative risks.

Requirements

• Bachelor’s degree required; MBA preferred.
• Active, unrestricted clinical license in an applicable discipline, such as RN, LCSW, LPC, LMFT, PharmD, MD/DO, or another relevant clinical field.
• 10+ years of experience in CM/UM risk management, regulatory compliance, process improvement, or a related area, including 6+ years in leadership.
• Advanced knowledge of CM/UM operational controls, risk mitigation, and Medicare and Medicaid regulatory requirements.
• Experience with internal controls, clinical and operational risk management, and IT technical controls in CM/UM environments.
• Exceptional project management, communication, collaboration, integrity, business ethics, and executive presence.

Culture & Benefits

• Full-time schedule of 40 hours per week.
• Remote work with occasional office travel for training or meetings.
• Dedicated workspace required to protect member PHI and HIPAA information.
• Home internet must provide at least 25 Mbps download and 10 Mbps upload speeds.
• Work focuses on member access to care, operational compliance, risk mitigation, and continuous improvement.