Director of Clinical Policy

Integrated Home Care Services, Inc. • Miramar, FL

7h

About The Position

The Director of Clinical Policy – Home Health and DME Services is responsible for leading the development, implementation, and continuous improvement of clinical policies, criteria, and workflows supporting home health and durable medical equipment (DME) services across all lines of business. This role ensures that clinical criteria are evidence-based, operationally efficient, and aligned with Medicare, Medicaid, and commercial payer requirements. This individual will partner closely with clinical operations, utilization management, technology, and product teams to design and optimize scalable, automated workflows that enhance efficiency, compliance, and quality of care delivery in the home setting.

Requirements

• Clinical Policy & Criteria Development
• Regulatory Monitoring & Compliance
• Workflow Design & Automation
• Collaboration & Cross-Functional Leadership
• Quality & Continuous Improvement
• Governance & Oversight

Responsibilities

• Lead the development, standardization, and maintenance of clinical criteria for all home health and DME services across lines of business.
• Translate Medicare (NCDs/LCDs), Medicaid, and commercial payer policies into actionable, operational clinical guidelines.
• Ensure clinical criteria are evidence-based, auditable, and aligned with regulatory and accreditation standards.
• Establish governance processes for ongoing review, approval, and updates to clinical policies and decision logic.
• Maintain up-to-date knowledge of Medicare and Medicaid regulations, including coverage determinations, billing requirements, and policy updates.
• Interpret regulatory changes and proactively incorporate them into clinical criteria and workflows.
• Ensure compliance with CMS, NCQA, and other regulatory bodies, including utilization management (UM) standards and timelines.
• Partner with Technology, Analytics, Quality, and Operations teams to design and implement automated clinical workflows for prior authorization and care coordination.
• Translate clinical policies into decision trees, rules engines, and system logic to support scalable automation.
• Identify opportunities to reduce manual review, improve turnaround times, and enhance provider and member experience.
• Support integration of clinical criteria into authorization platforms, EHRs, and workflow tools.
• Collaborate with Medical Directors, UM teams, care management, and provider engagement teams to ensure alignment of clinical policies and operational workflows.
• Serve as a clinical subject matter expert in product development, payer strategy, and operational initiatives.
• Partner with provider networks to support understanding and adoption of clinical criteria and documentation standards.
• Monitor utilization trends, denial patterns, and workflow performance to identify improvement opportunities.
• Lead continuous improvement initiatives focused on quality, consistency, and efficiency of clinical decision-making.
• Ensure clinical criteria support high-quality, cost-effective care and appropriate utilization of services.
• Chair or participate in clinical policy committees, UM governance forums, and interdisciplinary workgroups.
• Support audit readiness and responses for internal and external reviews.
• Maintain documentation and version control for all clinical policies and criteria.

Benefits

• Medical
• Vision
• Dental
• Short- and Long-term insurance
• 6+ Days of Holidays Pay
• 17 days of PTO
• Employer paid life insurance
• 401K with employer contribution
• Wellness program with reward incentives
• Employee recognition and reward programs
• Comprehensive paid training program

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: No Education Listed