[Hiring] Claims Configuration Senior Manager @Devoted Health

Role Description

At Devoted, we understand that building trust hinges on our ability to pay claims accurately and on time, and to clearly communicate those outcomes to our members and providers. The Senior Manager, Claims Adjudication Logic will be the subject matter expert on how our claims move through the system: the rules that determine whether a claim auto-adjudicates or pends for manual review, how claims are matched to the correct provider contract, and how outcomes are communicated through Explanations of Benefits (EOBs), Explanations of Payment (EOPs), and remittance advice. This person will own the accuracy, integrity, and strategic direction of our claims back-end logic.

The ideal candidate is a curious, detail-oriented problem solver who enjoys tracing a claim from intake to payment, takes ownership of issues from discovery to resolution, and thinks strategically about how to build a more accurate, automated, scalable, and cost-effective claims operation.

Responsibilities and Impact

• Auto-Adjudication Strategy & Performance:
  • Own our auto-adjudication rate as a core operational metric.
  • Develop a deep understanding of the flags and pend reasons that route claims to manual review.
  • Evaluate each for business value, accuracy, and operational cost.
  • Partner with engineering to retire, refine, or automate flags that no longer serve their purpose.
  • Design new flags where risk warrants human review.
• Contract Group Matching:
  • Serve as the go-to expert on how claims are matched to provider contracts and contract groups.
  • Identify and resolve mismatches that lead to incorrect payment.
  • Partner with Provider Operations and Network to ensure the intent of contracts is aligned with claims processing.
• EOB & EOP Logic:
  • Own the logic that generates member EOBs and provider EOPs.
  • Ensure they accurately reflect adjudication outcomes, member cost share, and denial or adjustment reasons.
  • Ensure member-facing communications meet CMS requirements and are clear and understandable.
  • Ensure provider-facing communications give providers what they need to reconcile payments.
• Claims Remit Support:
  • Serve as the subject matter expert on remittance outputs, including 835/ERA files and payment reconciliation.
  • Support providers, Provider Services, and Engineering in resolving remit issues caused by claims processing.
  • Drive fixes to root causes rather than one-off workarounds.
• Issue Identification & Root Cause Analysis:
  • Proactively identify adjudication, matching, and communication errors.
  • Lead root cause analysis and drive sustainable fixes in collaboration with Engineering, Claims Operations, and Network/Provider Operations.
• Accuracy & Governance:
  • Establish and own the framework for measuring claims logic performance.
  • Build the audits, validation testing, KPIs, and reporting that give leadership confidence in our payment outcomes.
• Proactive Optimization:
  • Look ahead to regulatory changes, new contract structures, and emerging technology.
  • Recommend improvements that reduce manual touch, payment errors, provider abrasion, and operational risk.

Qualifications

• 6+ years of experience in business operations or operational leadership.
• Comfort with ambiguity and a willingness to dive deep into complex claims system logic.
• Exceptional communication skills, with the ability to explain complex claims logic to both technical and non-technical audiences.
• Demonstrated success in driving meaningful change and measurable operational results in fast-paced environments.
• Strong analytical skills, with experience building and developing KPIs.
• Ability to work with large claims datasets to diagnose adjudication outcomes and quantify operational and financial impact.
• Thrives in a fast-paced, metrics-driven environment, with the ability to prioritize and manage multiple initiatives at once.

Desired Skills and Experience

• Curiosity and hands-on experience with AI tools, automation, or LLM-based workflows in operational settings is highly desired.
• Knowledge of health insurance claims processing, particularly Medicare Advantage.
• Experience partnering with Engineering on rules-based systems, workflow design, or claims platform development.

Salary Range

$110,500 - $150,000 annually. The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting.

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.
• And more....