Payment Integrity Program Development Manager

Devoted Health, Inc.

Job Overview

Location

Remote USA

Job Type

Full-time

Full Job Description

📋 Description

• Serve as a premier coding and billing regulations expert in a high-autonomy, outcomes-driven Individual Contributor (IC) role, designing innovative payment integrity concepts across prospective pre- and post-payment edits and audits.
• Manage the full lifecycle of edit and audit development—from hypothesis formation to detailed rule design—translating complex medical policies, CMS guidelines, AMA/CPT guidance, and coding regulations into precise, actionable software logic with defined conditions, exclusions, thresholds, and flags.
• Run data queries to validate financial hypotheses and author technical specification documents, using modern AI tools to generate and edit SQL scripts; must be able to read, interpret, and validate data outputs to confirm edit efficacy.
• Design defensible payment policies that supplement CMS guidance when necessary, anticipating provider appeals and disputes by embedding clear explanatory narratives directly into rule logic to reduce friction and enhance compliance.
• Continuously optimize active payment integrity rules post-release by analyzing real-world performance data, reducing false positives, and adjusting for evolving provider behaviors and claim trends.
• Leverage large language models (LLMs) and automated pattern-matching tools to review claim data trends, accelerate narrative development, and streamline the translation of clinical and billing signals into automated payment logic.
• Map identified billing anomalies directly to primary regulatory sources including CMS LCDs, NCDs, LCAs, NCCI bundling frameworks, and AMA coding mandates to ensure regulatory defensibility and audit readiness.
• Plan, organize, and coordinate discrete payment integrity initiatives to meet measurable accuracy goals and deadlines, proactively identifying and resolving operational bottlenecks in the concept pipeline.
• Collaborate cross-functionally with Payment Integrity Directors, internal auditors, SIU teams, and claims operations to ensure coding and billing appropriateness, regulatory alignment, and strategic coordination across departments.
• Maintain deep familiarity with institutional/facility billing rules including MS-DRG, APR-DRG, APC/OPPS, and revenue codes, as well as Medicare Advantage framework guidelines.
• Apply expertise in Pharmacy Part D parameters and High-Cost Drugs under Part B, including dosing, wastage, compounding, and J-code configurations, to develop accurate payment logic for complex pharmaceutical claims.
• Utilize industry claims rules platforms such as Optum/CES, Cotiviti, or McKesson to inform and implement payment integrity logic.

🎯 Requirements

• Bachelor’s degree and minimum 4 years of relevant professional experience in a health plan, payment integrity vendor, or healthcare revenue cycle environment
• Proven subject matter expertise in interpreting CMS policies (LCDs, NCDs, LCAs), NCCI bundling edits, and provider manuals
• Demonstrated experience writing logic rules or structural guidelines for claims processing implementation
• Demonstrated ability to plan, organize, and coordinate individual concepts and initiatives with strong problem-solving skills to meet deadlines
• Strong analytical literacy to read, interpret, and validate data query scripts or advanced spreadsheets to confirm edit efficacy and coding hypotheses

🏖️ Benefits

• Employer-sponsored health, dental, and vision plans 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
• 401K program

Skills & Technologies

Remote

$73k-0k

Degree Required

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Devoted Health, Inc.

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About Devoted Health, Inc.

Devoted Health, Inc. operates as a Medicare Advantage health plan provider, offering comprehensive coverage, personalized care navigation, and integrated technology to seniors across the United States. The company combines clinical expertise, data analytics, and member support services to coordinate physician visits, prescription management, and preventive care, aiming to improve health outcomes and reduce unnecessary costs for its members.

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