Payment Integrity Program Development Senior Manager

Job Description

A bit about this role:

At Devoted, our mission is to build trust with our providers and members by ensuring claims are paid accurately and on time with transparent policies. Our Payment Integrity Concept Development Department is at the forefront of this effort, ensuring provider claims are paid correctly, free of errors, and aligned with contractual terms.

As our Payment Integrity Program Development Senior Manager, you will serve as a senior payment integrity subject matter expert operating in a high-autonomy, outcomes-driven Individual Contributor (IC) role. You will work across the concept lifecycle to identify and develop new medical cost savings opportunities, evaluate the performance of existing concepts, and solve complex payment accuracy problems. You will combine coding and billing expertise, reimbursement policy, data analytics, and operational insight to translate complex findings into defensible payment integrity solutions.

This role requires independent judgment, professional creativity, and the ability to lead complex, multi-phase work across functions. You will have flexibility to operate where your expertise can have the greatest impact—from developing new concepts to investigating systemic issues and strengthening the performance of the active portfolio.

Your responsibilities and impact will include:

• Concept Development & Opportunity Identification: Independently identify, research, and develop payment integrity opportunities using claims trends, coding and reimbursement guidance, internal signals, industry practices, and AI-enabled research and analytics. Translate complex findings into discrete, defensible edit or audit concepts.
• Concept Design & Validation: Develop and refine payment integrity logic, including applicable codes, thresholds, exclusions, source authority, financial opportunity, defensibility, and maintenance considerations. Use claims data and analytical tools to test hypotheses and validate concept performance.
• Portfolio Assurance & Optimization: Evaluate active concepts to ensure they continue to operate accurately and effectively. Investigate performance anomalies, emerging risks, provider disputes, regulatory changes, and operational signals to determine when concepts require maintenance, correction, redesign, or retirement.
• Complex Root Cause Analysis & Remediation: Lead complex investigations involving concept performance or payment accuracy. Determine root cause and impact, develop appropriate remediation strategies, and coordinate resolution across Payment Integrity, Claims, Data Science, Engineering, Product, and other partners.
• Program & Process Improvement: Identify recurring weaknesses, inefficiencies, and risks across the concept lifecycle and develop scalable improvements to processes, controls, monitoring, documentation, and workflows.
• Regulatory & Policy Interpretation: Interpret CMS guidance, NCCI frameworks, reimbursement policies, coding guidance, contracts, internal policies, and other authoritative sources and translate them into defensible payment integrity decisions and requirements.
• AI Workflow Adoption: Use large language models (LLMs) and other AI-enabled tools to accelerate research, claims analysis, concept development, documentation, and investigation while independently validating outputs and applying appropriate subject matter judgment.
• Cross-Functional Leadership & Influence: Serve as a senior Payment Integrity subject matter expert across matrixed teams. Develop recommendations, articulate a clear point of view, resolve ambiguity, and bring cross-functional partners together to achieve measurable payment accuracy and medical cost outcomes.
• Project & Portfolio Management: Independently lead complex, multi-phase initiatives and manage competing priorities across new development and active portfolio needs. Proactively identify obstacles, risks, and dependencies and drive work through resolution.

Required skills and experience:

• Bachelor's degree and a minimum of 6 years of relevant professional experience within a health plan, payment integrity vendor, healthcare revenue cycle environment, or related healthcare setting.
• Strong subject matter expertise in healthcare claims, coding and billing, reimbursement, payment integrity, or related healthcare payment operations.
• Demonstrated experience developing, evaluating, maintaining, or optimizing payment integrity edits, audits, reimbursement rules, claims logic, or comparable healthcare controls.
• Demonstrated ability to independently investigate complex claims or payment issues, perform root cause analysis, and translate findings into actionable solutions.
• Strong analytical literacy with the ability to evaluate claims datasets and read, interpret, and validate data query scripts or advanced analytical outputs.
• Demonstrated ability to lead complex, multi-phase work across multiple functions with limited oversight.
• Strong independent judgment and ability to develop recommendations where policy, data, or operational signals may be incomplete or ambiguous.
• Strong communication and influencing skills with the ability to bring together cross-functional partners and leaders around complex decisions.

Desired skills and experience:

• Active Certified Professional Coder (CPC) designation or similar professional coding, reimbursement, or healthcare credential.
• Experience interpreting CMS policies, NCCI edits, LCD/NCD guidance, provider manuals, reimbursement policies, and other healthcare payment authorities.
• Experience with Medicare Advantage and prospective and/or retrospective payment integrity programs.
• Familiarity with industry claims rules platforms and payment integrity vendor solutions.
• Experience using SQL, AI-enabled analytical tools, or other methods to investigate claims populations and test payment integrity hypotheses.

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.