Medical Director, Payment Integrity - Remote (PA/NJ/DE)

The Medical Director, Clinical Payment Integrity provides clinical oversight of payment integrity programs, reimbursement policy interpretation, provider engagement, and payment accuracy initiatives. This role serves as the clinical bridge between the health plan, providers, and internal stakeholders, ensuring payment integrity activities are clinically sound, operationally effective, and aligned with contractual and regulatory requirements.

Partners closely with Utilization Management, Quality, Network Management, Payment Integrity, Informatics, Legal, and Compliance teams to advance payment accuracy, affordability, provider collaboration, and healthcare quality.

This is an opportunity to help establish and expand a growing Clinical Payment Integrity function, influencing future strategy, governance, program development, and provider engagement capabilities.

Key Responsibilities

Clinical Payment Integrity Oversight & Reviews

• Conduct physician-level clinical reviews and render medical determinations for post-service payment reviews, clinical validation audits, appeals, disputes, and escalated reimbursement matters.
• Interpret clinical documentation, claims data, coding practices, and reimbursement policies to determine alignment with clinical findings and payment guidelines.
• Support development of payment integrity policies, audit methodologies, clinical review processes, and reimbursement strategies.
• Partner with analytics, operations, payment integrity, and policy teams to identify trends, improve review accuracy, and strengthen programs.
• Serve as the physician escalation point for complex clinical payment integrity cases requiring medical judgment and interpretation.
• Support efforts to prevent fraud, waste, and abuse while ensuring fair and accurate reimbursement practices.

Provider Engagement & Partnership

• Serve as a senior clinical liaison to provider organizations, fostering relationships with physicians, revenue cycle leaders, coding teams, and healthcare executives.
• Lead provider discussions regarding payment policies, audit methodologies, coding interpretations, reimbursement decisions, and review findings.
• Partner with providers to resolve recurring billing, coding, documentation, and reimbursement issues through education and collaboration.
• Represent the organization in executive-level meetings, Joint Value Committees (JVCs), Joint Operating Committees (JOCs), and other provider forums to discuss payment accuracy, utilization trends, quality outcomes, claim reviews, disputes, appeals, and improvement opportunities.
• Act as the physician escalation point for provider concerns, balancing clinical appropriateness, coding standards, contractual requirements, reimbursement policy, and provider perspectives.
• Solicit provider feedback and incorporate insights into education and operational improvement efforts.

Clinical Leadership, Strategy & Cross-Functional Collaboration

• Collaborate with Utilization Management Medical Directors, Quality Clinical Leaders, Network Management, Provider Relations, Analytics, Legal, Compliance, and Operational teams to align payment integrity activities, reimbursement policies, medical necessity determinations, and provider communications.
• Ensure provider perspectives and clinical workflows inform payment integrity initiatives, reimbursement policies, and review processes.
• Serve as a clinical leader in the development and governance of payment integrity policies, audit methodologies, reimbursement strategies, and clinical review frameworks.
• Lead root-cause analyses of audit findings, provider disputes, and payment integrity trends to improve processes and payment accuracy.
• Develop clinical guidance, best practices, and educational resources for internal teams.
• Coach and mentor clinical reviewers, nurses, coding specialists, and other payment integrity professionals.
• Partner with organizational leaders to shape and expand the Clinical Payment Integrity function, including its strategy, governance, operating model, review methodologies, and physician review capabilities.
• Champion solutions that improve payment accuracy, operational effectiveness, provider experience, affordability, and healthcare value.

Required Qualifications

• Active, unrestricted physician license and current board certification.
• Minimum seven (7) years of clinical practice experience.
• Experience in managed care, utilization management, payment integrity, revenue cycle management, health plan operations, clinical auditing, or related healthcare leadership functions.
• Demonstrated experience conducting clinical reviews and rendering medical determinations in support of utilization management, payment integrity, reimbursement review, or clinical audit activities.
• Strong knowledge of CPT, ICD-10, HCPCS, clinical documentation requirements, and healthcare reimbursement methodologies.
• Experience interpreting and applying payment policies, clinical guidelines, medical necessity criteria, and regulatory requirements.
• Experience managing complex provider disputes, appeals, and reimbursement-related escalations.
• Strong communication and relationship management skills with the ability to effectively engage providers, executives, and cross-functional stakeholders.
• Ability to work effectively in a dynamic, matrixed healthcare environment.

Preferred Qualifications

• Experience as a Health Plan Medical Director, Physician Advisor, or comparable physician leadership role.
• Experience with clinical validation audits, DRG validation, reimbursement policy, payment integrity operations, or healthcare payment review programs.
• Experience participating in Joint Value Committees (JVCs), provider governance forums, and executive-level provider engagement activities.
• Knowledge of value-based care, provider economics, quality measurement, healthcare affordability initiatives, and payment integrity strategies.
• Experience building new programs, leading change initiatives, or establishing clinical governance and review capabilities.