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