Senior Manager, Payment Integrity Program Development – Clinical & Facility Specialist

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $110.5k - $150k / year

⏰ Full Time

🟠 Senior

👔 Manager

👻 Ghost score 0%

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Devoted Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2017

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Devoted Health is a healthcare company that offers Medicare Advantage plans designed to provide comprehensive health coverage with added benefits like dental, eyewear, gym memberships, and prescription drugs at competitive rates. The company emphasizes member support and service, ensuring that clients can easily navigate their benefits and access needed healthcare services. Devoted Health is committed to helping customers save money and enhance their health and wellness through a complete package of benefits and support.

📋 Description

• Research clinical literature, specialty society guidelines, and multi-setting billing trends to identify payment anomalies and formulate original edit hypotheses • Author end-to-end automated payment integrity logic from scratch • Translate clinical documentation, medical policies, and facility/professional coding frameworks into precise logic parameters • Perform data analysis using modern AI tools for SQL query generation to test hypotheses and validate financial viability • Design parameters that prevent provider abrasion • Present original clinical concepts to directors and executive stakeholders • Drive consensus across Clinical Operations, SIU, Claims, and Legal on policy interpretations and rule architectures • Lead concept rollouts from clinical discovery through selection criteria, logic testing, post-launch tuning, and long-term performance tracking • Apply clinical expertise across inpatient, outpatient, Ambulatory Surgical Center, and professional settings

🎯 Requirements

• An active Registered Nurse (RN) license with direct inpatient clinical experience (e.g., ICU, Med-Surg) • An active professional coding certification (e.g., CPC, CCS, CCS-P, or RHIA) • 5+ years of experience in payment integrity where you were the primary author and creator of net-new claim edits within a health plan or vendor setting • Expert understanding of core Medicare rules, billing regulations, Local/National Coverage Determinations (LCDs/NCDs), and NCCI edit logic across care settings • Deep working knowledge of facility and professional billing dynamics, including inpatient (MS-DRG/APR-DRG), outpatient/ASC (APC/OPPS, fee schedules), and professional CPT/HCPCS clinical guidelines • Direct experience authoring detailed rules and structural logic specifications for implementation in commercial claims editing engines (e.g., Optum/CES, Cotiviti, McKesson) or payer proprietary/internal rules platforms • Proven ability to synthesize complex clinical specialty guidelines into structured logic • Ability to read, interpret, and validate data queries (SQL assistance provided via modern AI tools) • Exceptional narrative and framing skills with a track record of building cross-functional alignment around complex, original technical concepts • Specialized experience applying rules and coverage determinations specifically within a Medicare Advantage (MA) managed care environment • Familiarity with using AI workflows, large language models (LLMs), or automated pattern-matching tools to accelerate data analysis, literature review, and rule development

🏖️ Benefits

• Employer sponsored health, dental and vision plan with low or no premium • Generous paid time off • $100 monthly mobile or internet stipend • Stock options for all employees • Bonus eligibility for all roles excluding Director and above • Commission eligibility for Sales roles • Parental leave program • 401K program