Payment Integrity Program Development Senior Manager – Clinical & Facility Speci
Job Description
A bit about this role:
As our Senior Payment Integrity Program Development Manager, you will serve as the primary clinical architect and inventor behind Devoted’s clinical claim edit and audit pipeline. Operating in a high-autonomy, outcomes-driven individual contributor role, you will conduct independent clinical research, interpret specialty society guidelines, and analyze multi-setting billing data to originate brand-new, automated payment integrity logic from scratch.
While complex, high-dollar inpatient care forms a critical foundation of this role, you will also apply your clinical acumen across outpatient, Ambulatory Surgical Center (ASC), and professional settings to ensure a continuous, high-impact pipeline of payment integrity concepts.
Your responsibilities and impact will include:
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Greenfield Concept Ideation: Drive ground-up innovation by researching clinical literature, specialty society guidelines, and multi-setting billing trends (Inpatient, Outpatient, ASC, and Professional) to identify hidden payment anomalies and formulate original edit hypotheses.
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Primary Logic Architecture: Author end-to-end logics from scratch. Translate raw clinical documentation, medical policies, and facility/professional coding frameworks (MS-DRG, APR-DRG, APC/OPPS, ASC packaging, and CPT/HCPCS rules) into precise, automated logic parameters.
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Data Hypothesis Validation: Perform primary data analysis (utilizing modern AI tools for SQL query generation) to test your clinical hypotheses across clinical settings, prove financial viability on real-world datasets, and design parameters that prevent provider abrasion.
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Cross-Functional Policy Leadership: Pitch your original clinical concepts to directors and executive stakeholders; drive consensus across Clinical Operations, SIU, Claims, and Legal to approve novel policy interpretations and rule architectures.
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End-to-End Concept Ownership: Lead multi-phased concept rollouts across clinical settings—from initial clinical discovery through selection criteria, logic testing, post-launch tuning, and long-term performance tracking.
Required skills and experience:
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Clinical & Coding Credentials: An active Registered Nurse (RN) license with direct inpatient clinical experience (e.g., ICU, Med-Surg) AND an active professional coding certification (e.g., CPC, CCS, CCS-P, or RHIA).
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Net-New Concept Authoring: 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 (as opposed to evaluating pre-built edit catalogs or executing client implementation requests).
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Medicare & Regulatory Foundation: Expert understanding of core Medicare rules, billing regulations, Local/National Coverage Determinations (LCDs/NCDs), and NCCI edit logic across care settings.
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Multi-Setting Clinical & Facility Mastery: 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.
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Hands-On Logic Writing: 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.
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Research & Data Literacy: Proven ability to synthesize complex clinical specialty guidelines into structured logic, paired with the analytical ability to read, interpret, and validate data queries (SQL assistance provided via modern AI tools).
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Senior-Level Influence: Exceptional narrative and framing skills with a track record of building cross-functional alignment around complex, original technical concepts.
Desired skills and experience:
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Specialized experience applying rules and coverage determinations specifically within a Medicare Advantage (MA) managed care environment.
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Familiarity with using AI workf