To address the difficulty of simultaneously achieving effective heat dissipation and adequate humidification in open cathode air cooled proton exchange membrane fuel cells (PEMFCs) under medium and high power operation, this study proposes a hydrothermal management strategy based on coordinated ultrasonic atomization humidification and fan speed regulation. A three dimensional single cell multiphysics model is developed and validated using a 300 W experimental platform. The effects of atomization frequency and water temperature on stack performance and internal hydrothermal distribution are systematically investigated. Results show that ultrasonic atomization provides inlet precooling, latent heat absorption, and active region humidification, thereby improving hydrothermal uniformity within the stack. Under the optimal condition of 100 kHz and 55 °C, the peak stack power increases by 21.0% to 319.00 W, while voltage consistency and surface temperature uniformity are also improved. Analysis based on the Stokes number and Dalton’s law of partial pressures indicates that the optimum results from a balance between suppressing droplet agglomeration and inertial deposition, and limiting oxygen dilution caused by excessive water vapor. The proposed strategy provides a compact and practical approach for improving the stability, uniformity, and efficiency of air cooled PEMFCs.