Medical Director, Payment Integrity & Utilization Management

TL;DR

Medical Director, Payment Integrity & Utilization Management (Medicare Advantage): Perform detailed medical record reviews to ensure documentation supports services rendered and aligns with medical necessity guidelines with an accent on payment integrity, utilization management, and cost containment. Focus on validating clinical decisions, coaching decision-makers, collaborating on aberrant trends investigations, and championing initiatives to reduce unnecessary utilization.

Location: Remote - USA

Salary: $270,000–$300,000

Company

hirify.global is a Medicare Advantage plan integrating technology and clinical data to improve member outcomes through better care management.

What you will do

• Perform detailed medical record reviews like 30-day readmissions to confirm medical necessity and proper documentation.
• Review and validate vendor/provider clinical decisions for accurate reimbursement.
• Coach and train clinical decision-makers on medical necessity guidelines.
• Contribute to peer review committees and quality improvement initiatives.
• Lead cost containment efforts by investigating trends with data analytics, claims, and fraud teams.
• Collaborate with providers on case reviews for consistent decision-making.

Requirements

• MD or DO with valid, unrestricted license to practice medicine in a US State
• Board Certified, preferably in Internal Medicine, Family Medicine, or Emergency Medicine
• At least 5 years clinical experience including inpatient
• Strong experience in Payment Integrity and Utilization Management/Review
• Solid understanding of Medicare Advantage
• Experience with peer review committees
• Detail-oriented with strong clinical judgment and problem-solving mindset
• Thrive in collaborative, cross-functional settings with tech proficiency

Culture & Benefits

• Competitive base salary, equity, performance bonus, 401k matching
• Comprehensive medical, dental, vision coverage
• Remote-first culture with no-meeting Fridays, monthly holidays, flexible time-off
• Mental health resources, paid parental leave
• Professional development: learning programs, mentorship, funding
• Perks: ESPP, office setup reimbursement, cell/internet stipend