Senior Medical Director (Claims)

TL;DR

Senior Medical Director (Claims): Provide strategic oversight for development, validation, and improvement of pre-payment edits ensuring payment integrity in healthcare with an accent on clinical rationale, medical policy, and regulatory compliance. Focus on analyzing complex clinical scenarios, advising executives and customers, and representing the organization in industry forums and collaborations.

Location: Remote (US)

Salary: $211,551 - $317,326

Company

AI-first platform-based healthcare technology company preventing inaccurate payments and reducing waste in the healthcare ecosystem.

What you will do

• Assist with pre-pay edit development, maintenance, and communication including clinical scenarios, medical policy, and necessity reviews.
• Approve and provide clinical rationale for custom editing concepts.
• Support product strategy on edit inclusion in content groups.
• Participate in analytic reviews of clinical content to identify trends and opportunities.
• Act as trusted advisor on healthcare trends, interacting with executives, customers, and internal stakeholders.
• Host webinars, content review calls, and conduct on-site customer visits as needed.

Requirements

• Board-certified physician (MD or DO) with at least 10 years active clinical experience, preferably in Internal Medicine or Family Practice
• 3+ years as Medical Director for a health insurance payer
• AAPC CPC or AHIMA CCS-P certification (required or within 6 months of hire)
• Deep understanding of disease processes, evidence-based medicine, payer operations, claims adjudication, and payment integrity
• Experience with utilization management, medical policy, regulatory compliance
• Strong analytical, leadership, communication, and problem-solving skills
• Up-to-date knowledge of healthcare regulations and industry standards

Nice to have

• Strong Medical Director/CMO background in health plans, payment integrity, and claims management
• Excellent verbal, written, and multi-media communication skills
• Strong interpersonal skills and creative problem-solving

Culture & Benefits

• Inclusive environment empowering employees and collaborative success
• HI-TRUST and SOC2 certified with top industry recognitions
• Total rewards compensation beyond base salary