Job Description
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 Manager you will serve as a premier coding and billing regulations expert operating in a high-autonomy, outcomes-driven Individual Contributor (IC) role. We give our managers creative liberty to design innovative concepts across the entire spectrum of prospective pre- and post-payment edits and audits. You will bridge coding and billing expertise, regulatory policy, and data analytics to transform complex guidelines into intelligent, automated payment integrity software logic . Your responsibilities and impact will include: Innovative Concept & Rule Development (The Crux of the Role): 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. Hypothesis Testing & Data Querying: 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. (Note: We provide modern AI tools to generate and edit SQL scripts; you do not need to be a software expert, but you must possess the ability to read, interpret, and understand data scripts to validate results and analyze proof-of-concept datasets). Defensible Policy & Friction Management: Design payment policies where CMS guidance needs to be supplemented to ensure defensibility in supporting the concept. Proactively anticipate downstream appeal behaviors and pr
