Senior Manager, Payment Integrity Program Development – Clinical & Facility Specialist
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Job Description
Payment integrity manager creating automated clinical claim edits for Devoted Health’s senior-care platform. Applying RN, coding, Medicare, and multi-setting billing expertise.
Responsibilities:
- 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
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