Medical Policy Director in United States at Jobgether

This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Medical Policy Director in United States.

This role sits at the intersection of clinical expertise, medical policy strategy, and client engagement, driving how healthcare payment policies are developed, refined, and adopted by health plan partners. You will act as a trusted subject matter expert in coding and reimbursement policy, shaping discussions that directly influence claims accuracy and financial optimization. Working closely with clinical and client leadership, you will help translate complex medical policy frameworks into clear, data-driven insights. The position combines analytical rigor, presentation leadership, and strategic advisory responsibilities in a highly collaborative, client-facing environment. You will play a central role in evaluating policy opportunities, validating financial impact, and guiding adoption of optimized medical editing rules. This is a high-impact role where clinical knowledge meets strategic consulting to improve payment integrity at scale.

The Medical Policy Director serves as a subject matter expert in medical payment policy and coding, leading client-facing discussions and internal policy governance activities. This role is responsible for analyzing claims data, identifying policy optimization opportunities, and presenting recommendations that improve payment integrity and financial outcomes.

• Act as a subject matter expert for medical policy, coding standards, and payment integrity rules within a comprehensive policy library.
• Analyze client data to identify opportunities for new or improved medical policies, including validation of financial and operational impact.
• Select and prepare real claim examples to support policy presentations and client understanding.
• Develop presentation materials and supporting documentation for internal committees and external client meetings.
• Lead and deliver policy presentations, clearly articulating rationale, data insights, and expected impact.
• Collaborate with clinical leaders and client stakeholders to validate edits and support adoption of new policies.
• Participate in client engagements as a trusted advisor and ensure timely follow-up on deliverables and action items.
• Identify opportunities to expand solution adoption and strengthen client value through policy optimization.

This role requires deep expertise in medical coding, claims adjudication, and healthcare payment policy, combined with strong client-facing communication and analytical capabilities. The ideal candidate is both a strategic thinker and a confident presenter who can translate complex data into actionable insights.

• Bachelor’s degree in a relevant field or equivalent experience.
• Professional coding certification required (CPC, CPC-A, CCA, CCS, or CCS-P); RHIT or RHIA preferred.
• 7–10 years of relevant experience in healthcare, client services, or related fields.
• At least 5 years of experience in claims adjudication, medical policy editing, or reimbursement policy using Medicare/Medicaid and coding standards (ICD, CPT, HCPCS).
• Health plan, managed care, or insurance industry experience preferred.
• Strong presentation skills with the ability to influence and communicate across technical and executive audiences.
• Excellent analytical and problem-solving skills with the ability to interpret complex datasets.
• Strong organizational skills with the ability to manage multiple priorities in a fast-paced environment.
• Proficiency in Microsoft Office tools, including Word, Excel, PowerPoint, and Outlook.
• Ability to work independently in a remote environment with limited supervision.

• Competitive base salary ranging from $120,000 to $145,000 annually, with eligibility for discretionary bonus.
• Comprehensive healthcare coverage including medical, dental, vision, disability, and life insurance.
• 401(k) retirement savings plan.
• Generous paid time off (17–27 days depending on tenure) plus 9 paid holidays annually.
• Paid family leave and family support benefits.
• Fully remote work environment within the continental United States.
• Flexible, stable working conditions with strong emphasis on autonomy and accountability.
• Opportunity to contribute to high-impact healthcare policy optimization at scale.