Payment Integrity Program Development Senior Manager – Clinical & Facility Specialist (Medicare Advantage)

Location: Remote USA

Salary: $110,500–$150,000 per year

Company

hirify.global is a healthcare company founded in 2017 that combines clinical and service experiences with data and AI to improve care for older Americans.

What you will do

• Research clinical literature, specialty society guidelines, and billing trends to identify payment anomalies and develop original claim-edit hypotheses.
• Translate clinical documentation, medical policies, and facility and professional coding frameworks into automated logic parameters.
• Analyze claims data, using AI-assisted SQL query generation, to validate hypotheses, financial impact, and provider-impact safeguards.
• Present original concepts to directors and executives and align Clinical Operations, SIU, Claims, and Legal stakeholders.
• Own concepts from clinical discovery and selection criteria through testing, launch tuning, and long-term performance tracking.

Requirements

• Active RN license and direct inpatient clinical experience, such as ICU or Med-Surg.
• Active professional coding certification, such as CPC, CCS, CCS-P, or RHIA.
• 5+ years of payment integrity experience creating net-new claim edits within a health plan or vendor environment.
• Expertise in Medicare rules, billing regulations, LCDs, NCDs, and NCCI edit logic across care settings.
• Deep knowledge of inpatient, outpatient, ASC, and professional billing, including MS-DRG, APR-DRG, APC/OPPS, ASC packaging, CPT, and HCPCS.
• Experience writing detailed rules and logic specifications for commercial claims-editing engines or proprietary payer platforms, plus the ability to interpret and validate data queries.

Nice to have

• Medicare Advantage managed-care experience.
• Experience with AI workflows, large language models, or automated pattern-matching tools for data analysis, literature review, or rule development.

Culture & Benefits

• Remote work in the USA.
• Employer-sponsored health, dental, and vision plans with low or no premium.
• Generous paid time off and parental leave.
• $100 monthly mobile or internet stipend.
• Stock options for all employees, bonus eligibility for eligible roles, and a 401(k) program.