Claims Configuration Senior Manager

Devoted Health Services; United States; Remote; USD 111,000 - 150,000; Full time

Job summary

Devoted Health Services in the United States is seeking a Senior Manager, Claims Adjudication Logic to own and optimize back-end rules that drive auto-adjudication and manual review decisions. You will oversee EOBs/EOPs and remittance outputs, ensuring accurate, compliant, and timely payments.

The role requires deep claims system knowledge, strong analytics, and ability to partner with Engineering, Claims Operations, and Network/Provider Operations to reduce errors and costs.

Qualifications

• 6+ years of experience in business operations or operational leadership.
• Ability to dive deep into complex claims system logic.
• Exceptional communication skills for technical and non-technical audiences.
• Proven track record delivering measurable operational results in fast-paced environments.
• Strong analytical skills with KPI development and large dataset work.

Responsibilities

• Own auto-adjudication strategy and performance metrics.
• Match claims to provider contracts and contract groups; resolve mismatches.
• Own EOB/EOP logic to reflect adjudication outcomes.
• Support remittance outputs (835/ERA) and provider payment reconciliation.
• Lead root cause analysis for adjudication, matching, and communication errors.
• Establish governance framework with KPIs, audits, and reporting.
• Identify regulatory changes and propose automation to reduce manual touch.

Skills

Auto-adjudication

KPIs

Cross-functional leadership

Data analysis

Communication

Tools

835/ERA files

Job description

Job Description

A bit about this role:

At Devoted, we understand that building trust hinges on our ability to pay claims accurately and on time, and to clearly communicate those outcomes to our members and providers. The Senior Manager, Claims Adjudication Logic will be the subject matter expert on how our claims move through the system: the rules that determine whether a claim auto-adjudicates or pends for manual review, how claims are matched to the correct provider contract, and how outcomes are communicated through Explanations of Benefits (EOBs), Explanations of Payment (EOPs), and remittance advice. This person will own the accuracy, integrity, and strategic direction of our claims back-end logic.

The ideal candidate is a curious, detail-oriented problem solver who enjoys tracing a claim from intake to payment, takes ownership of issues from discovery to resolution, and thinks strategically about how to build a more accurate, automated, scalable, and cost-effective claims operation.

Your Responsibilities and Impact will include:

• Auto-Adjudication Strategy & Performance: Own our auto-adjudication rate as a core operational metric. Develop a deep understanding of the flags and pend reasons that route claims to manual review. Evaluate each for business value, accuracy, and operational cost. Partner with engineering to retire, refine, or automate flags that no longer serve their purpose, and design new ones where risk warrants human review.
• Contract Group Matching: Serve as the go-to expert on how claims are matched to provider contracts and contract groups, including provider identifiers, TIN/NPI relationships, network status, effective dates, and contract hierarchy. Identify and resolve mismatches that lead to incorrect payment, and partner with Provider Operations and Network to ensure the intent of contracts is aligned with claims processing.
• EOB & EOP Logic: Own the logic that generates member EOBs and provider EOPs, ensuring they accurately reflect adjudication outcomes, member cost share, and denial or adjustment reasons. Ensure member-facing communications meet CMS requirements and are clear and understandable, and that provider-facing communications give providers what they need to reconcile payments.
• Claims Remit Support: Serve as the subject matter expert on remittance outputs, including 835/ERA files and payment reconciliation. Support providers, Provider Services, and Engineering in resolving remit issues caused by claims processing, and drive fixes to root causes rather than one-off workarounds.
• Issue Identification & Root Cause Analysis: Proactively identify adjudication, matching, and communication errors, lead root cause analysis, and drive sustainable fixes in collaboration with Engineering, Claims Operations, and Network/Provider Operations.
• Accuracy & Governance: Establish and own the framework for measuring claims logic performance, including auto-adjudication rate, manual adjudication rates by reason, contract match accuracy, EOB/EOP accuracy, and remit-related provider inquiries. Build the audits, validation testing, KPIs, and reporting that give leadership confidence in our payment outcomes.
• Proactive Optimization: Look ahead to regulatory changes, new contract structures, and emerging technology to recommend improvements that reduce manual touch, payment errors, provider abrasion, and operational risk.

Required skills and experience:

• 6+ years of experience in business operations or operational leadership
• Comfort with ambiguity and a willingness to dive deep complex claims system logic to fully understand how things work
• Exceptional communication skills, with the ability to explain complex claims logic to both technical and non-technical audiences
• Demonstrated success in driving meaningful change and measurable operational results in fast-paced environments, with a bias toward action and a focus on continuous improvement
• Strong analytical skills, with experience building and developing KPIs, and the ability to work with large claims datasets to diagnose adjudication outcomes and quantify operational and financial impact
• Thrives in a fast-paced, metrics-driven environment, with the ability to prioritize and manage multiple initiatives at once

Desired skills and experience:

• Curiosity and hands-on experience with AI tools, automation, or LLM-based workflows in operational settings is highly desired
• Knowledge of health insurance claims processing, particularly Medicare Advantage, including adjudication workflows, provider contracting, and regulatory and compliance requirements
• Experience partnering with Engineering on rules-based systems, workflow design, or claims platform development

#LI-remote

Salary range: $110,500 - $150,000 annually

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional infor