Medical Director

Machinify

Medical Director overseeing clinical audit programs for a healthcare intelligence company. Provides medical oversight for governmental and commercial payer claims audits with a focus on regulatory compliance.

Posted 7/21/2026full-timeRemote • 🇺🇸 United StatesLeadWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical leadership and medical oversight for audit programs, with a strong focus on regulatory compliance, payer policies, and clinical documentation accuracy. Proficient in evaluating medical necessity and coding accuracy while collaborating with multidisciplinary teams to resolve complex clinical issues.

Highest-signal resume keywords

Medical Degree (MD or DO)Active Medical LicenseClinical Patient Care ExperienceExperience with Medicare and MedicaidAudit and Compliance Expertise

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewCoding Accuracy EvaluationMedical Necessity AssessmentAudit Methodologies SupportQuality Assurance ProcessesClinical Validation FrameworksUtilization ManagementClaims AuditPayment Integrity ReviewRegulatory Compliance Monitoring

Soft Skills

LeadershipCollaborationCommunicationProblem-SolvingContinuous Improvement

Certifications & Qualifications

Board Certification in ABMS or AOA Specialty

Industry Keywords

Medicare AdvantageManaged CareCommercial Payer PoliciesInpatient MedicineEmergency MedicineUtilization Management OrganizationPayment Integrity VendorAudit CompanyHealthcare ComplianceClinical Practice Trends

About the role

Key responsibilities & impact

Provide clinical leadership and medical oversight for audit programs involving governmental and commercial payer claims.
Review and interpret medical records, claims data, coding patterns, clinical documentation, and payer policies to support accurate audit determinations.
Evaluate medical necessity, level of care, site of service, coding accuracy, documentation sufficiency, and alignment with applicable clinical standards and payer requirements.
Support audit methodologies, clinical validation frameworks, sampling approaches, and quality assurance processes to ensure consistency, defensibility, and regulatory alignment.
Apply knowledge of Medicare, Medicaid, Medicare Advantage, managed care, and commercial payer policies to audit findings, provider education, and client deliverables.
Partner with audit operations, coding, clinical review, data analytics, compliance, legal, and client-facing teams to resolve complex clinical and payment integrity issues.
Provide physician-level review and support for disputes, rebuttals, grievances, appeals, and provider-facing clinical explanations.
Participate in the development and maintenance of clinical audit guidelines, review protocols, policy interpretation tools, and reviewer training materials.
Monitor regulatory updates, payer policy changes, coding guidance, clinical practice trends, and audit risk areas that may affect governmental or commercial payer work.
Support client engagements by explaining clinical rationale, audit findings, documentation expectations, and defensible review standards.
Promote clinical accuracy, reviewer consistency, ethical audit practices, and continuous improvement across medical review operations.
Other related job duties, as assigned by executive leadership.

Requirements

What you’ll need

Medical degree (MD or DO) required.
Active, unrestricted medical license in good standing required; willingness to obtain additional licensure may be preferred based on business needs.
Board certification in an ABMS or AOA-recognized specialty preferred.
Minimum of 5+ years of direct clinical patient care experience post-residency or fellowship required; experience in inpatient, post-acute, emergency medicine, hospital medicine, internal medicine, surgery, or a payer-relevant specialty preferred.
Experience with governmental payer programs, including Medicare, Medicaid, and/or Medicare Advantage, strongly preferred.
Experience with commercial payer policies, managed care operations, utilization management, medical necessity review, claims audit, coding review, appeals, or payment integrity preferred.
No current sanctions, exclusions, or restrictions from federal or state governmental healthcare programs.
Prior experience in an audit company, payer organization, payment integrity vendor, utilization management organization, or highly regulated healthcare environment strongly preferred.

Benefits

Comp & perks

Equal Employment Opportunity at Machinify