Clinical Manager (Payment Integrity)

TL;DR

Clinical Manager (Payment Integrity): Bridging clinical expertise and business operations to evaluate carrier reimbursements and ensure billing accuracy with an accent on NCCI guidelines and medical record auditing. Focus on leading the clinical analyst team, designing efficient clinical processes, and translating data insights into operational improvements.

Location: Remote

Company

hirify.global is an industry-insider firm dedicated to reducing healthcare spending for self-funded employers through proprietary data analysis.

What you will do

• Review medical records and claims for billing accuracy and compliance with NCCI guidelines.
• Lead, manage, and mentor the department’s Clinical Analysts.
• Partner with cross-functional teams to design and refine clinical processes that improve outcomes.
• Prepare carrier responses and lead referral calls with carrier networks and clients.
• Analyze clinical and operational data to identify trends, risks, and opportunities for improvement.
• Collaborate with IT to define business and reporting requirements for departmental initiatives.

Requirements

• Active clinical license (RN, LPN/LVN) or equivalent clinical experience.
• Certification such as CPC, CCS, or similar clinical/coding credential.
• 5+ years of experience in TPA/Carrier claims processing or payment integrity.
• 5+ years of experience in healthcare administration, billing, or clinical auditing.
• Proven experience as a people leader managing a team.
• Strong analytical skills with proficiency in Excel or data visualization tools.

Nice to have

• Experience working with commercial health plans.
• Proficiency with EMR systems and clinical documentation tools.
• Advanced degree in Nursing, Healthcare Administration, or Business.

Culture & Benefits

• Opportunity to make a meaningful impact on healthcare costs.
• Collaborative environment working with industry insiders.
• Focus on continuous improvement and professional growth.
• Supportive team culture with emphasis on clear communication and accountability.