Payment Integrity Program Development Senior Manager

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States.  And we've just started. So join us on this mission!

Job Description

A bit about this role: 

• At Devoted, we know that one of the most important ways we will build trust with our network of providers and members  is to pay claims accurately and on time while having transparent payment policies. Our Payment Integrity Department ensures that provider claims are paid correctly by the responsible party, for eligible members, according to contractual terms, not in error or duplicate, and free of wasteful or abusive practices.

• As a Payment Integrity Program Development Senior Manager, you will be responsible for identifying and  researching new medical cost savings opportunities to improve claim payment accuracy and reduce the overall medical spend. You will assess new opportunities by leveraging your subject matter expertise, researching and evaluating CMS policies and industry trends,  analyzing Devoted claims performance, and cross-functional collaboration.

Your Responsibilities and Impact will include:

• Leverage your subject matter expertise, policy research, industry trends, and internal and publicly available data to generate ideas

• Collaborate with internal teams to identify claims payment inaccuracies, root cause, and the impact on medical expense

• Proactively and independently analyze medical cost trending, claim processing trends, overpayments, and other claim and medical expense irregularities to identify opportunities to reduce cost, improve claim adjudication accuracy, introduce payment policy changes, and develop new payment integrity program

• Independently create and iterate data sets to research ideas and develop data insights 

• Develop opportunity sizing models to estimate financial impact, prevalence, and ROI for potential payment integrity concepts.

• Partner with Clinical & Policy SMEs to validate data-driven findings against medical necessity and regulatory requirements.
  Maintain and prioritize a concept backlog based on opportunity size, compliance risk, and implementation feasibility.

• Score and rank concepts using structured criteria (effort vs. ROI, member/provider impact, vendor feasibility).

• Monitor CMS updates, OIG/RAC findings, and industry trends to identify emerging areas of risk and cost growth.

• Incorporate external benchmarks and best practices to inform opportunity assessments.

Required skills and experience:

• Bachelor's degree and a minimum of 5 years of relevant experience in health plan analytics, medical economics, or payment integrity.

• Demonstrated ability to translate complex data into actionable strategies that drive measurable savings.

• Strong command of claims data (facility, professional, pharmacy) and healthcare reimbursement methodologies (DRG, APC, CPT/HCPCS, NDC).

• Understanding of US healthcare

• Proficiency in a variety of analytical and data mining tools to generate ideas, analyze data sets, and perform root cause analysis

• Strong communications skills (verbal, written, presentation, interpersonal) with all types/levels of audience

• Ability to multitask and effectively prioritize critical tasks and conflicting requirements

• Ability to understand, explain, and break down complex problems

Desired skills and experience:

• Proficiency with SQL

• Knowledge of claims adjudication, revenue cycle management, and payment integrity

• Familiarity with CMS regulations and NCDs/LCDs .

#LI-Remote
#LI-DS1
 

Salary range: $105,000 - $155,000 / year

Our ranges are purposefully broad to allow for growth within the role over time. 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 may 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.

Healthcare equality is at the center of Devoted’s mission to treat our members like family.  We are committed to a diverse and vibrant workforce. 

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.