Claims Configuration Senior Manager

Job description

Job Description A bit about this role: 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. Your Responsibilities and Impact will include: 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, and design new ones 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, including provider identifiers, TIN/NPI relationships, network status, effective dates, and contract hierarchy. Identify and resolve mismatches that lead to incorrect payment, and 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, ensuring 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, and that 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, and 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, including auto-adjudication rate, manual adjudication rates by reason, contract match accuracy, EOB/EOP accuracy, and remit-related provider inquiries. 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 to recommend improvements that reduce manual touch, payment errors, provider abrasion, and operational risk. Required skills and experience: 6+ years of experience in business operations or operational leadership Comfort with ambiguity and a willingness to dive deep complex claims system logic to fully understand how things work 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, with a bias toward action and a focus on continuous improvement Strong analytical skills, with experience building and developing KPIs, and the 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, including adjudication workflows, provider contracting, and regulatory and compliance requirements Experience partnering with Engineering on rules-based systems, workflow design, or claims platform development #LI-remote 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. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: 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.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.