Note: The job is a remote job and is open to candidates in USA. Devoted Health is on a mission to improve the health and well-being of older Americans by providing integrated healthcare solutions. The Payment Integrity Program Development Manager role focuses on ensuring claims are paid accurately and on time by managing the lifecycle of edit and audit development and bridging coding, billing expertise, and regulatory policy.
Responsibilities
- Manage the full lifecycle of edit and audit development — from initial coding and billing hypothesis to detailed rule design
- Convert complex medical policy, CMS rules, AMA/CPT guidance, and coding regulations into actionable logic specifications, mapping out precise conditions, exclusions, thresholds, and flags
- Must be capable of running data queries to prove the financial validity of a coding and billing hypothesis and authoring the resulting technical specification document
- Design payment policies where CMS guidance needs to be supplemented to ensure defensibility in supporting the concept
- Proactively anticipate downstream appeal behaviors and provider disputes to craft strong explanatory narratives within the rule design
- Post-release, improve concept efficacy, false positives, and provider abrasion, continuously refining active rules based on real-world results and updated behavioral trends
- Use large language models (LLMs) or automated pattern-matching tools to review claim trends and develop narratives, accelerating the translation of signal into active payment logic
- Connect identified billing anomalies directly to published primary defense sources, including CMS guidelines, NCCI bundling frameworks, LCD/NCD rules, and AMA coding mandates
- Plan, organize, and coordinate discrete initiatives and concepts to achieve specific, measurable payment accuracy goals and deadlines
- Proactively identify pipeline obstacles, problem-solve execution blocks, and implement logic adjustments to drive greater efficiency
- Partner with PI Directors, internal auditors, SIU, and claims operations to ensure coding and billing appropriateness, regulatory compliance, and cross-functional strategic alignment
Skills
- Bachelor's degree and a minimum of 4 years of relevant professional experience within a health plan, payment integrity vendor, or healthcare revenue cycle environment
- Proven subject matter expertise as a coding and billing regulations expert, with deep familiarity interpreting CMS policies (LCDs, NCDs, LCAs), NCCI bundling edits, and provider manuals
- Demonstrated experience and comfort with concept development logic, including a proven track record of writing logic rules or structural guidelines for claims processing implementation
- Demonstrated ability to plan, organize, and coordinate individual concepts and initiatives, utilizing strong problem-solving skills to clear operational obstacles and meet deadlines
- Strong analytical literacy with the ability to read, interpret, and validate data query scripts or advanced spreadsheets to confirm edit efficacy and check coding and billing hypotheses
- Active Certified Professional Coder (CPC) designation or similar professional coding certification
- Advanced experience with institutional/facility billing rules (MS-DRG, APR-DRG, APC/OPPS, revenue codes) and facility packaging workflows
- Direct experience analyzing, writing, or defending concepts regarding Pharmacy Part D parameters and High-Cost Drugs under Part B (dosing, wastage, compounding, and J-code configurations)
- Additional national credentials such as Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), or Registered Health Information Administrator (RHIA)
- Familiarity with industry claims rules platforms (e.g., Optum/CES, Cotiviti, McKesson) and Medicare Advantage framework guidelines
Benefits
- 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
Company Overview