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Salary: USD 110,500 - 150,000 / annual
Devoted Health seeks a Senior Manager for Payment Integrity Program Development to architect and innovate the company's clinical claim edit and audit pipeline. This is a high-autonomy, outcomes-driven individual contributor role focused on creating net-new payment integrity logic from the ground up.
Key responsibilities include: conducting independent clinical research and interpreting specialty society guidelines to identify payment anomalies; authoring end-to-end logic architectures that translate clinical documentation and medical policies (MS-DRG, APR-DRG, APC/OPPS, ASC packaging, CPT/HCPCS) into automated parameters; performing primary data analysis using modern AI tools to validate clinical hypotheses across inpatient, outpatient, ASC, and professional settings; pitching original clinical concepts to directors and executives to drive cross-functional consensus; and leading multi-phased concept rollouts from discovery through post-launch tuning and performance tracking.
Required qualifications: active RN license with direct inpatient clinical experience (ICU, Med-Surg) AND active professional coding certification (CPC, CCS, CCS-P, or RHIA); 5+ years in payment integrity as a primary author of net-new claim edits within a health plan or vendor setting; expert understanding of Medicare rules, billing regulations, LCDs/NCDs, and NCCI edit logic; deep working knowledge of facility and professional billing dynamics across care settings; direct experience authoring rules and logic specifications for commercial claims editing engines (Optum/CES, Cotiviti, McKesson) or payer proprietary platforms; proven ability to synthesize clinical guidelines into structured logic and validate data queries; and senior-level influence with exceptional narrative skills for building cross-functional alignment.
Desired: specialized experience in Medicare Advantage managed care environments and familiarity with AI workflows, LLMs, or automated pattern-matching tools for accelerating data analysis and rule development.
