Director, Claim Payment Accuracy (Healthcare/AI)

TL;DR

Director, Claim Payment Accuracy (Healthcare/AI): Architecting the strategic roadmap for claim payment precision and quality oversight for a Medicare Advantage plan with an accent on clinical and reimbursement policy maintenance. Focus on implementing AI-driven automation for monitoring, optimizing vendor performance, and ensuring flawless adjudication of claims.

Location: Remote (USA)

Salary: $150,000 - $195,000 USD

Company

hirify.global is a Medicare Advantage plan that leverages custom software and data-driven insights to provide personalized, high-quality healthcare.

What you will do

• Own the development and maintenance of clinical and reimbursement policies in alignment with CMS regulations.
• Design and oversee a multi-layered global quality audit framework to monitor adjudication system output.
• Lead AI initiatives using LLMs (Claude, Gemini, ChatGPT) to automate policy monitoring and data-driven audit sampling.
• Manage strategic oversight of external BPaaS partners to maintain world-class payment accuracy standards.
• Act as a strategic bridge between Clinical, Claims, Compliance, and Configuration teams to synchronize benefit design and contractual terms.

Requirements

• Must be based in the USA.
• 8+ years of leadership experience in healthcare claims, payment accuracy, or policy oversight, with a focus on Medicare Advantage.
• Expertise in HealthEdge HRP and Source systems.
• Proficiency in applying emerging AI technologies and LLMs to operational precision and research.
• Proven track record of interpreting and operationalizing complex clinical policies and pricing models.
• Experience in strategic vendor oversight and data-driven leadership using sophisticated dashboards.

Nice to have

• Coding certifications such as CPC, CCS, COC, or CIC.

Culture & Benefits

• Competitive base salary, equity opportunities, and a performance-based bonus program.
• Comprehensive medical, dental, and vision coverage with 401k matching.
• Remote-first culture featuring No-Meeting Fridays and monthly company holidays.
• Generous flexible time-off policy and professional development funding.
• Financial perks including ESPP, reimbursement for office setup, and monthly cell phone and internet stipends.