Payment Integrity Program Development Manager (Healthcare)

TL;DR

Payment Integrity Program Development Manager (Healthcare): Designing and managing innovative payment integrity concepts and automated billing logic for a healthcare platform with an accent on CMS regulatory compliance, coding accuracy, and data-driven rule development. Focus on translating complex medical policies into actionable software logic, validating hypotheses through data analysis, and optimizing claim processing performance.

Location: Must be based in the USA

Salary: $73,000–$120,000 / year

Company

hirify.global is an all-in-one healthcare company dedicated to improving the well-being of older Americans through integrated insurance, clinical care, and technology.

What you will do

• Manage the full lifecycle of payment edit and audit development, from hypothesis to technical specification.
• Convert complex medical policies, CMS rules, and coding regulations into actionable automated logic.
• Validate coding and billing hypotheses by interpreting data queries and analyzing proof-of-concept datasets.
• Design defensible payment policies and proactively manage potential provider disputes or appeals.
• Refine active rules post-release to improve efficacy and reduce provider abrasion.
• Utilize AI tools and LLMs to identify claim trends and accelerate the translation of signals into payment logic.

Requirements

• Must be based in the USA
• Bachelor's degree and 4+ years of experience in a health plan, payment integrity vendor, or revenue cycle environment.
• Deep expertise in interpreting CMS policies (LCDs, NCDs, LCAs), NCCI bundling edits, and provider manuals.
• Proven ability to write logic rules or structural guidelines for claims processing implementation.
• Strong analytical literacy with the ability to read and interpret data query scripts or advanced spreadsheets.
• Demonstrated project management skills to coordinate initiatives and meet measurable accuracy goals.

Nice to have

• Active Certified Professional Coder (CPC) or similar certification (CCS, CCS-P, RHIA).
• Experience with institutional/facility billing rules (MS-DRG, APC/OPPS).
• Knowledge of Pharmacy Part D parameters and High-Cost Drugs under Part B.
• Familiarity with industry claims platforms like Optum/CES, Cotiviti, or McKesson.

Culture & Benefits

• Employer-sponsored health, dental, and vision plans with low or no premiums.
• Stock options for all employees and bonus eligibility.
• 401K program and parental leave.
• $100 monthly mobile or internet stipend.
• Generous paid time off and a mission-driven, collaborative work environment.