Remote Clinical Payment Integrity Director

Independence Blue Cross, LLC; Philadelphia (Philadelphia County); Remote; USD 200,000 - 320,000; Full time

Job summary

Independence Blue Cross, LLC seeks a Medical Director, Clinical Payment Integrity to provide clinical oversight of payment integrity programs, reimbursement policy interpretation, provider engagement, and related initiatives. This fully remote role supports the TriState area and collaborates across departments to ensure clinically sound and financially responsible payment decisions.

The position partners with Utilization Management, Quality, Network Management, Payment Integrity, and Compliance

Responsibilities

• Conduct physician-level clinical reviews and render medical determinations for postservice 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.
• 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.

Job description

Independence Blue Cross, LLC seeks a Medical Director, Clinical Payment Integrity to provide clinical oversight of payment integrity programs, reimbursement policy interpretation, provider engagement, and related initiatives. This fully remote role supports the TriState area and collaborates across departments to ensure clinically sound and financially responsible payment decisions.

The position partners with Utilization Management, Quality, Network Management, Payment Integrity, and Compliance