Senior Manager, Payment Integrity Program Development – Clinical & Facility Specialist

Devoted Health

Payment integrity manager creating automated clinical claim edits for Devoted Health’s senior-care platform. Applying RN, coding, Medicare, and multi-setting billing expertise.

Posted 8/22/2026full-timeRemote • 🇺🇸 United StatesSenior💰 $110,500 - $150,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in payment integrity, clinical documentation translation, and automated logic development, with a strong focus on Medicare rules and billing regulations. Proven ability to lead cross-functional initiatives and synthesize complex clinical guidelines into actionable logic parameters.

Highest-signal resume keywords

Registered Nurse (RN) LicenseProfessional Coding Certification (CPC, CCS, CCS-P, RHIA)5+ Years Experience in Payment IntegrityExpert Understanding of Medicare Rules and Billing RegulationsExperience with Claims Editing Engines (Optum/CES, Cotiviti, McKesson)

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Applicant Tracking System Keywords

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Hard Skills

Payment Integrity Logic DevelopmentData Analysis Using SQLClinical Documentation TranslationRule Authoring and Logic SpecificationsUnderstanding of Local/National Coverage Determinations (LCDs/NCDs)Knowledge of Inpatient and Outpatient Billing DynamicsSynthesis of Clinical Specialty GuidelinesValidation of Data QueriesAutomated Pattern-Matching ToolsAI Workflow Familiarity

Soft Skills

Exceptional Narrative SkillsFraming SkillsCross-Functional AlignmentConsensus BuildingCommunication Skills

Tools & Technologies

AI Tools for SQL Query GenerationAutomated Payment Integrity Logic ToolsClaims Editing EnginesLarge Language Models (LLMs)

Certifications & Qualifications

Registered Nurse (RN) LicenseProfessional Coding Certification (CPC, CCS, CCS-P, RHIA)

Industry Keywords

Medicare Advantage (MA)Inpatient Clinical ExperienceAmbulatory Surgical Center (ASC)Fee SchedulesCPT/HCPCS Clinical Guidelines

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

Research clinical literature, specialty society guidelines, and multi-setting billing trends to identify payment anomalies and formulate original edit hypotheses
Author end-to-end automated payment integrity logic from scratch
Translate clinical documentation, medical policies, and facility/professional coding frameworks into precise logic parameters
Perform data analysis using modern AI tools for SQL query generation to test hypotheses and validate financial viability
Design parameters that prevent provider abrasion
Present original clinical concepts to directors and executive stakeholders
Drive consensus across Clinical Operations, SIU, Claims, and Legal on policy interpretations and rule architectures
Lead concept rollouts from clinical discovery through selection criteria, logic testing, post-launch tuning, and long-term performance tracking
Apply clinical expertise across inpatient, outpatient, Ambulatory Surgical Center, and professional settings

Requirements

What you’ll need

An active Registered Nurse (RN) license with direct inpatient clinical experience (e.g., ICU, Med-Surg)
An active professional coding certification (e.g., CPC, CCS, CCS-P, or RHIA)
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
Expert understanding of core Medicare rules, billing regulations, Local/National Coverage Determinations (LCDs/NCDs), and NCCI edit logic across care settings
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
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
Proven ability to synthesize complex clinical specialty guidelines into structured logic
Ability to read, interpret, and validate data queries (SQL assistance provided via modern AI tools)
Exceptional narrative and framing skills with a track record of building cross-functional alignment around complex, original technical concepts
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

Benefits

Comp & perks

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