[Hiring] Payment Integrity Program Development Senior Manager @Devoted Health

Role Description

As our Senior Payment Integrity Program Development Manager, you will serve as the primary clinical architect and inventor behind Devoted’s clinical claim edit and audit pipeline. Operating in a high-autonomy, outcomes-driven individual contributor role, you will conduct independent clinical research, interpret specialty society guidelines, and analyze multi-setting billing data to originate brand-new, automated payment integrity logic from scratch.

Your responsibilities and impact will include:

• Greenfield Concept Ideation: Drive ground-up innovation by researching clinical literature, specialty society guidelines, and multi-setting billing trends (Inpatient, Outpatient, ASC, and Professional) to identify hidden payment anomalies and formulate original edit hypotheses.
• Primary Logic Architecture: Author end-to-end logics from scratch. Translate raw clinical documentation, medical policies, and facility/professional coding frameworks (MS-DRG, APR-DRG, APC/OPPS, ASC packaging, and CPT/HCPCS rules) into precise, automated logic parameters.
• Data Hypothesis Validation: Perform primary data analysis (utilizing modern AI tools for SQL query generation) to test your clinical hypotheses across clinical settings, prove financial viability on real-world datasets, and design parameters that prevent provider abrasion.
• Cross-Functional Policy Leadership: Pitch your original clinical concepts to directors and executive stakeholders; drive consensus across Clinical Operations, SIU, Claims, and Legal to approve novel policy interpretations and rule architectures.
• End-to-End Concept Ownership: Lead multi-phased concept rollouts across clinical settings—from initial clinical discovery through selection criteria, logic testing, post-launch tuning, and long-term performance tracking.

Qualifications

• 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, paired with the analytical 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

Requirements

• 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
• And more...