Payment Integrity Program Development Senior Manager – Clinical & Facility Specialist

Job description

Job Description A bit about this role: 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. While complex, high-dollar inpatient care forms a critical foundation of this role, you will also apply your clinical acumen across outpatient, Ambulatory Surgical Center (ASC), and professional settings to ensure a continuous, high-impact pipeline of payment integrity concepts. 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. Required skills and experience: Clinical & Coding Credentials: An active Registered Nurse (RN) license with direct inpatient clinical experience (e.g., ICU, Med-Surg) AND an active professional coding certification (e.g., CPC, CCS, CCS-P, or RHIA). Net-New Concept Authoring: 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 (as opposed to evaluating pre-built edit catalogs or executing client implementation requests). Medicare & Regulatory Foundation: Expert understanding of core Medicare rules, billing regulations, Local/National Coverage Determinations (LCDs/NCDs), and NCCI edit logic across care settings. Multi-Setting Clinical & Facility Mastery: 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. Hands-On Logic Writing: 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. Research & Data Literacy: 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). Senior-Level Influence: Exceptional narrative and framing skills with a track record of building cross-functional alignment around complex, original technical concepts. Desired skills and experience: 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. #LI-DS1 #LI-Remote Salary range: $110,500 - $150,000 / year 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.