Remote: Senior Payment Integrity Architect & Innovator

Remote Jobs; United States; Remote; USD 111,000 - 150,000; Full time

Benefits offered by this job

Health plan

Paid time off

Stipend

Stock options

Bonus eligibility

Parental leave

401K

Job summary

Devoted Health is seeking a Senior Payment Integrity Program Development Manager to architect and invent the clinical claim edit and audit pipeline. You will lead ground-up development of automated logic across inpatient, outpatient, ASC, and professional settings.

You will translate clinical documentation, policies, and CPT/HCPCS rules into precise logic, validate hypotheses with data, and drive cross-functional policy leadership to scale the program.

Qualifications

• Active RN license with inpatient clinical experience (ICU/Med-Surg) and an active professional coding certification (CPC/CCS/CCS-P/RHIA).
• 5+ years in payment integrity as primary author of net-new claim edits in a health plan or vendor setting.
• Expert understanding of Medicare rules, LCDs/NCDs, and NCCI edit logic across care settings.
• Deep knowledge of inpatient (MS-DRG/APR-DRG), outpatient/ASC (APC/OPPS), and professional CPT/HCPCS guidelines.
• Hands-on experience drafting rules for commercial claims engines (Optum/CES, Cotiviti, McKesson).
• Strong data literacy and ability to translate guidelines into structured logic; SQL with AI-assisted queries.
• Senior-level ability to build cross-functional alignment around complex technical concepts.

Responsibilities

• Greenfield concept ideation by researching literature, guidelines, and billing trends to identify payment anomalies and formulate original edit hypotheses.
• Primary logic architecture: translate coding frameworks into precise automated logic parameters.
• Data hypothesis validation: test clinical hypotheses with dataset analyses and design robust parameters.
• Cross-functional policy leadership: pitch concepts to directors and executives to gain consensus.
• End-to-end concept ownership: lead phased rollouts from discovery to post-launch tuning and tracking.

Skills

RN license

Professional coding certification

Payment integrity experience

MS-DRG/APR-DRG knowledge

CPT/HCPCS rules knowledge

Logic writing for claims engines

SQL data analysis

Cross-functional leadership

Senior-level influence

Tools

Optum/CES

Cotiviti

McKesson

Job description

Devoted Health is seeking a Senior Payment Integrity Program Development Manager to architect and invent the clinical claim edit and audit pipeline. You will lead ground-up development of automated logic across inpatient, outpatient, ASC, and professional settings.

You will translate clinical documentation, policies, and CPT/HCPCS rules into precise logic, validate hypotheses with data, and drive cross-functional policy leadership to scale the program.