Payment Integrity Program Development Senior Manager (Clinical & Facility)

Location: Remote USA

Salary: $110,500–$150,000 per year

Company

hirify.global is a healthcare company focused on improving the health and well-being of older Americans through an integrated care platform combining clinical services, data, and AI.

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 real-world data, using AI-assisted SQL workflows, to validate hypotheses, assess financial viability, and reduce provider abrasion.
• Present original concepts to directors and executives and build alignment across Clinical Operations, SIU, Claims, and Legal.
• Own concepts from clinical discovery and selection criteria through logic testing, rollout, post-launch tuning, and performance tracking.

Requirements

• Active Registered Nurse license with direct inpatient clinical experience, such as ICU or Med-Surg.
• Active professional coding certification, such as CPC, CCS, CCS-P, or RHIA.
• At least 5 years of payment integrity experience creating net-new claim edits within a health plan or vendor environment.
• Expert knowledge of 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, fee schedules, CPT, and HCPCS.
• Experience writing rules and structural logic specifications for commercial claims editing engines or proprietary payer platforms, plus the ability to interpret data queries and influence senior stakeholders.

Nice to have

• Experience applying coverage rules in a Medicare Advantage managed care environment.
• Familiarity with AI workflows, large language models, or automated pattern-matching tools for data analysis, literature review, and rule development.

Culture & Benefits

• Health, dental, and vision plans with low or no employee premiums.
• Generous paid time off and a parental leave program.
• $100 monthly mobile or internet stipend.
• Stock options and bonus eligibility for eligible roles.
• 401(k) program.
• Benefits apply to full-time employees; contract positions are not eligible.