Payment Integrity Clinical Readmission Manager

Location: Remote USA

Salary: $73,000–$125,000 annually

Company

hirify.global provides an integrated care platform combining data, AI, clinical care, and service experiences to improve the health and well-being of older Americans.

What you will do

• Conduct prepayment and post-payment clinical reviews of inpatient admissions and related readmissions within 30 days of discharge.
• Review claims and medical records to determine clinical relationships, potential preventability, and possible consolidation of admissions.
• Apply organizational policies, regulatory requirements, readmission criteria, and applicable exclusions.
• Prepare objective clinical rationales, findings, dispute responses, appeal letters, and supporting documentation.
• Collaborate with Payment Integrity, appeals, quality, and utilization management teams on complex or disputed cases.
• Participate in calibration, peer review, quality review, and process improvement activities.

Requirements

• Current, active, unrestricted RN license in at least one U.S. state is required.
• Five or more years of experience in clinical nursing, hospital-based care, healthcare audit, Payment Integrity, utilization management, quality review, or a related healthcare environment.
• Experience reviewing inpatient hospital readmissions, medical records, claims, and clinical information from multiple sources.
• Strong knowledge of inpatient care, disease processes, complications, discharge planning, and transitions of care.
• Ability to apply clinical criteria and regulatory guidance, exercise sound judgment, and produce clear, objective, defensible documentation.
• Strong analytical, organizational, communication, and collaboration skills, with experience using electronic medical records or clinical review systems.

Nice to have

• Bachelor of Science in Nursing or a related healthcare degree.
• Experience with health plan, hospital, Payment Integrity, or external audit readmission reviews.
• Experience with Medicare, Medicaid, commercial payer, QIO, State Operations Manual, or payer-specific criteria.
• Experience with disputes, appeals, clinical calibration, quality assurance, or process improvement.
• Familiarity with inpatient coding, DRG methodology, clinical validation, hospital bill audits, automation, or AI-supported review workflows.

Culture & Benefits

• Full-time remote work environment with opportunities to work independently and collaboratively.
• Employer-sponsored health, dental, and vision plans with low or no premium.
• Generous paid time off and parental leave.
• $100 monthly mobile or internet stipend.
• Stock options for all employees and a 401(k) program.