Remote Medical Director, Payment Integrity & Strategy

Independence Blue Cross; Philadelphia (Philadelphia County); Remote; USD 210,000 - 320,000; Full time

Job summary

Independence Blue Cross is seeking a Medical Director, Payment Integrity to provide clinical oversight of payment integrity programs and reimbursement policy interpretation. This remote role supports tri-state providers in PA, NJ, and DE and partners with Legal, Compliance, Analytics, and Network teams.

The role emphasizes physician leadership, policy development, and provider education to improve payment accuracy, reduce waste, and ensure compliant reimbursement across the organization.

Qualifications

• Active, unrestricted physician license and board certification.
• Minimum seven (7) years of clinical practice experience.
• Experience in managed care, utilization management, payment integrity, or related healthcare leadership functions.
• 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 reimbursement methodologies.
• Experience interpreting and applying payment policies, clinical guidelines, and regulatory requirements.
• Experience managing complex provider disputes, appeals, and reimbursement-related escalations.
• Strong communication and relationship management skills with providers, executives, and cross-functional stakeholders.

Responsibilities

• Provide clinical oversight of payment integrity programs and reimbursement policy interpretation.
• Serve as clinical liaison to providers, executives, and cross-functional teams.
• Lead development of payment integrity policies, audit methodologies, and review processes.
• Collaborate with analytics, operations, and policy teams to identify trends and improve accuracy.
• Act as physician escalation point for complex clinical payment integrity cases.
• Champion solutions that improve payment accuracy and provider experience.

Skills

Physician license

Board certification

Clinical experience

Managed care

Clinical reviews

Coding knowledge

Policy interpretation

Provider disputes

Communication

Adaptability

Job description

Independence Blue Cross is seeking a Medical Director, Payment Integrity to provide clinical oversight of payment integrity programs and reimbursement policy interpretation. This remote role supports tri-state providers in PA, NJ, and DE and partners with Legal, Compliance, Analytics, and Network teams.

The role emphasizes physician leadership, policy development, and provider education to improve payment accuracy, reduce waste, and ensure compliant reimbursement across the organization.