Medical Director - PI, Claims

Location: Remote nationwide within the United States; occasional travel to hirify.global offices for training or meetings may be required.

Salary: $223,800–$313,100 per year, plus eligibility for a bonus incentive plan.

Company

hirify.global is a U.S. healthcare and insurance company serving Medicare, Medicaid, military, individual, and community populations through hirify.global and CenterWell services.

What you will do

• Review clinical records and make initial or appeals-level determinations on requested services, levels of care, and sites of service.
• Interpret national clinical guidelines, CMS policies, hirify.global policies, clinical standards, and applicable contracts.
• Prioritize daily reviews involving inpatient, outpatient, rehabilitation, home health, and other post-acute care.
• Communicate determinations and discuss complex cases with physicians, nurses, case managers, care managers, and internal departments.
• Support utilization management, claims medical reviews, grievance and appeals processes, and care management activities.
• Participate in project teams and organizational committees focused on quality, population health, and disease or care management.

Requirements

• MD or DO degree and current, ongoing board certification through an approved ABMS or AOA medical specialty.
• At least 5 years of direct clinical patient care experience after residency or fellowship, including inpatient or outpatient care of Medicare-type populations.
• Current, unrestricted medical license in at least one U.S. jurisdiction and willingness to obtain additional licenses.
• Experience in utilization management, medical management review, quality management, case management, discharge planning, home health, or post-acute services.
• Knowledge of Medicare Advantage, Managed Medicaid, commercial insurance, managed care, health insurance, or integrated delivery systems.
• Ability to meet credentialing requirements with no current federal or state governmental sanctions.

Nice to have

• Multiple medical licenses.
• Experience with Medicare Advantage or Medicaid claims medical reviews.
• Exposure to public health, population health, analytics, and business metrics.
• Experience with complex case management, social determinants of health, and collaboration with case or care managers.
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, or Emergency Medicine specialization.

Culture & Benefits

• Remote work from a dedicated space that protects member PHI and HIPAA information.
• Home internet service must provide at least 25 Mbps download and 10 Mbps upload speeds.
• Medical, dental, and vision coverage, 401(k) retirement savings, paid time off, holidays, and paid parental and caregiver leave.
• Short- and long-term disability coverage, life insurance, wellness support, and other employee benefits.
• Full-time schedule of 40 hours per week with mentored training before independent daily work.