Lead Software Engineer Healthcare Payer SME — CapAdmin Platform

Alivi; Miami (FL); Hybrid; USD 140,000 - 180,000; Full time

Job summary

Alivi seeks a Lead Software Developer with deep healthcare payer domain expertise to bridge engineering execution and payer knowledge. The role supports CapAdmin development with SME guidance, owning architecture and ensuring complete domain requirements before coding.

The candidate mentors engineers, partners with Operations, Finance and Compliance, and contributes to new product line integrations while upholding quality and scalability.

Qualifications

• 6+ years software engineering experience in payer/TPA domain or claims administration software.
• Strong proficiency in enterprise languages (C#/.NET, Java).
• Relational databases experience and data modeling for payer systems.
• REST APIs, microservices, and integration patterns.
• Familiarity with AWS data/BI stack and CI/CD/devops practices.

Responsibilities

• Translate payer business requirements into clear, complete technical specifications before development.
• Lead architecture discussions, drive scalability and platform modernization.
• Mentor mid-level developers on healthcare payer concepts.
• Collaborate with Operations, Finance, and Compliance to validate logic end-to-end.

Skills

C# / .NET

Java

REST APIs

Microservices

Agile / Scrum

Mentor engineers

Bilingual English/Spanish

Tools

SQL Server

PostgreSQL

AWS

Redshift

QuickSight

Job description

Alivi is seeking a Lead Software Developer with deep healthcare payer domain expertise to join our CapAdmin platform team, our proprietary claims administration system supporting our TPA (Third-Party Administrator) operations. This is a hybrid technical-SME leadership role designed to bridge the gap between engineering execution and payer / claims business knowledge. The ideal candidate is a senior developer who has lived inside a payer or TPA platform someone who understands not just how to build software, but how claims, eligibility, capitation, COB, UM, and UB04 workflows actually function in a real payer environment. This role will directly support our CapAdmin Development Lead, owning architecture, requirements validation, and SME-level guidance ensuring features are built right the first time, with complete domain requirements captured before development begins.

Duties & Responsibilities

3.1 Healthcare Payer Domain Leadership (Primary Focus)

• UB04 / CMS-1500 institutional and professional claim form processing
• Coordination of Benefits (COB) — primary, secondary, tertiary payer logic
• Utilization Management (UM) — prior authorization, medical necessity, concurrent review integrations
• Capitation models — PMPM calculations, cap reconciliation, risk pool accounting, sub-cap arrangements
• Eligibility & enrollment (834 transactions)
• Claims adjudication rules, edits, and pricing logic

Translate complex payer business requirements into clear, complete technical specifications before development begins. Partner with Operations, Finance, and Compliance to validate claims and capitation logic end-to-end.

3.2 Technical Leadership

• Partner with the CapAdmin Development Lead to drive architecture, scalability, and platform modernization.
• Lead code reviews with a domain lens — catching not just code quality issues but business logic errors.
• Mentor mid-level developers on healthcare payer concepts they may not have prior exposure to.
• Contribute to design and implementation of new product line integrations (Ophthalmology, expanded COB, etc.).

3.3 Requirements & Quality Ownership

• Own the "requirements completeness" function — ensuring every feature has full payer-domain context before sprint commitment.
• Work directly with Business Analysts, QA, and Product to eliminate the root cause of most CapAdmin defects: incomplete requirements.
• Define and document acceptance criteria grounded in payer regulations and customer contracts.

3.4 Cross-Functional Collaboration

• Partner with Operations leadership on claims accuracy, capitation reconciliation, and customer-facing escalations.
• Support customer-facing technical conversations with payer clients (Sunshine Health, Humana, etc.) when domain expertise is needed.
• Collaborate with the Architecture, Security, and Data / BI teams on enterprise alignment.

Requirements

4.1 Healthcare Payer / TPA Experience (Non-Negotiable)

6+ years working inside a payer platform, TPA system, or claims administration software (e.g., Facets, QNXT, HealthRules, HealthEdge, TriZetto, EZ-CAP, or proprietary platforms).

• UB04 and CMS-1500 claim processing
• COB rules and logic (NAIC order of benefits, Medicare secondary payer)
• Utilization Management workflows
• Capitation models and reconciliation
• EDI transactions (837, 835, 834, 270/271, 278)
• Working knowledge of CPT, HCPCS, ICD-10, revenue codes, and place-of-service codes.
• Familiarity with CMS, state Medicaid, and commercial payer requirements.

4.2 Technical Experience

• 6+ years of professional software engineering experience.
• Strong proficiency in C# / .NET, Java, or similar enterprise languages.
• Solid experience with relational databases (SQL Server, PostgreSQL) and data modeling for claims / payer systems.
• Experience with REST APIs, microservices, and integration patterns.
• Familiarity with AWS (Redshift / AWS / QuickSight stack) is a strong plus.
• Comfortable with Agile / Scrum, CI/CD, and modern DevOps practices.
• Demonstrated ability to mentor engineers and translate domain knowledge across technical and business audiences.
• Strong written and verbal communication — able to participate in customer and executive-level conversations.
• Bilingual (English / Spanish) Spanish is a must.

5. Preferred Qualifications

• Prior experience at a TPA, MSO, IPA, or health plan in a technical leadership role.
• Experience with specialty benefits administration (vision, transportation, podiatry & therapy etc.).
• Familiarity with HITRUST, HIPAA, and HITECH compliance requirements for payer systems.
• Experience supporting Medicaid managed care (e.g., Sunshine Health, Humana, Florida Medicaid).
• Background in risk-based contracts, sub-capitation, and value-based care arrangements.