Integrity Program Development Manager

Overview

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. The Payment Integrity Concept Development Department leads this effort, guaranteeing provider claims are paid correctly, free of errors, and aligned with contractual terms. As the Payment Integrity Program Development Manager, you will serve as a premier coding and billing regulations expert in an individual‑contributor role, designing innovative concepts across pre‑ and post‑payment edits and audits.

• 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 precise conditions, exclusions, thresholds, and flags.
• Run data queries to validate the financial validity of coding and billing hypotheses and author technical specification documents.
• Design payment policies that supplement CMS guidance to ensure defensibility, anticipating appeal behaviors and provider disputes.
• Continuously refine active rules to improve concept efficacy, reduce false positives, and minimize provider abrasion based on real‑world results and evolving trends.
• Leverage large language models or automated pattern‑matching tools to review claim trends and develop narratives, accelerating the translation of signal into active payment logic.
• Map identified billing anomalies directly to published primary defense sources, including CMS guidelines, NCCI bundling frameworks, LCD/NCD rules, and AMA coding mandates.
• Plan, organize, and coordinate discrete initiatives and concepts to achieve measurable payment accuracy goals and deadlines, solving execution blocks and adjusting logic as needed.
• Partner with PI Directors, internal auditors, SIU, and claims operations to ensure coding and billing appropriateness, regulatory compliance, and cross‑functional alignment.

• Bachelor’s degree and a minimum of 4 years of relevant professional experience within a health plan, payment integrity vendor, or healthcare revenue cycle environment.
• Proven subject‑matter expertise as a coding and billing regulations expert, with deep familiarity interpreting CMS policies (LCDs, NCDs, LCAs), NCCI bundling edits, and provider manuals.
• Experience writing logic rules or structural guidelines for claims processing implementation.
• Strong analytical literacy, able to read, interpret, and validate data query scripts or advanced spreadsheets to confirm edit efficacy.
• Demonstrated ability to plan, organize, and coordinate individual concepts and initiatives, with strong problem‑solving skills to clear operational obstacles and meet deadlines.

• Active Certified Professional Coder (CPC) designation or similar professional coding certification.
• Advanced experience with institutional/facility billing rules (MS‑DRG, APR‑DRG, APC/OPPS, revenue codes) and facility packaging workflows.
• Direct experience analyzing, writing, or defending concepts regarding Pharmacy PartD parameters and High‑Cost Drugs under PartB (dosing, wastage, compounding, and J‑code configurations).
• Additional national credentials such as Certified Coding Specialist (CCS), Certified Coding Specialist – Physician‑Based (CCS‑P), or Registered Health Information Administrator (RHIA).
• Familiarity with industry claims rules platforms (e.g., Optum/CES, Cotiviti, McKesson) and Medicare Advantage framework guidelines.

Salary Range: $73,000 – $120,000 per year. Base salary offered will depend on qualifications, experience, location, and additional factors.

• Employer‑sponsored health, dental, and vision plans with low or no premium.
• Generous paid time off and a $100 monthly mobile or internet stipend.
• Stock options for all employees.
• Bonus eligibility for all roles (excluding Directors and above); commission eligibility for sales roles.
• Parental leave program and 401(k) plan.

We are an equal opportunity employer. We do not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our commitment to diversity and inclusion is reflected in our policies, values, and everyday practices.