Payment Integrity Program Development Senior Manager – Clinical & Facility Specialist

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: 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. 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. 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. 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. 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: 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). 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). Medicare & Regulatory Foundation: Expert understanding of core Medicare rules, billing regulations, Local/National Coverage Determinations (LCDs/NCDs), and NCCI edit logic across care settings. 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. 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. 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). 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: Specialized experience applying rules and coverage determinations specifically within a Medicare Advantage (MA) managed care environment. Familiarity with using AI workflows, large language models (LLMs), or automated