Payment Integrity Program Development Senior Manager

United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must possess a Bachelor's degree and at least 5 years of experience in health plan analytics, medical economics, or payment integrity. A strong understanding of claims data, including facility, professional, and pharmacy claims, along with healthcare reimbursement methodologies like DRG, APC, CPT/HCPCS, and NDC is required. Proficiency in analytical and data mining tools, strong communication skills for various audiences, and the ability to manage multiple priorities are essential. Desired skills include SQL proficiency, knowledge of claims adjudication, revenue cycle management, payment integrity, and familiarity with CMS regulations, NCDs, and LCDs.

Responsibilities

The Payment Integrity Program Development Senior Manager will identify and research new medical cost savings opportunities to enhance claim payment accuracy and reduce overall medical spend. This involves leveraging subject matter expertise, analyzing CMS policies and industry trends, and collaborating with internal teams to pinpoint claims payment inaccuracies and their root causes. The role includes analyzing medical cost and claim processing trends, developing new payment integrity programs, creating data sets for research, building opportunity sizing models, validating findings with SMEs, maintaining a concept backlog, and monitoring CMS updates and industry trends for emerging risks.

Skills

Payment Integrity

Medical Cost Savings

Claim Payment Accuracy

CMS Policies

Data Analysis

Cross-functional Collaboration

Medical Expense Analysis

Claim Processing Trends

Overpayment Identification

Devoted Health

Medicare Advantage plans with personalized support

About Devoted Health

Devoted Health provides Medicare Advantage plans aimed at simplifying and making healthcare more affordable for seniors aged 65 and older. Their plans include services like provider and pharmacy searches, prescription drug coverage, and preventive care rewards. Members pay premiums for these plans, and the company may also receive government payments for managing Medicare benefits. What sets Devoted Health apart from competitors is their high level of customer service, featuring Devoted Health Guides who assist members in navigating their healthcare options and addressing common issues with traditional insurance. Additionally, they promote preventive care through the Devoted Dollars program, which rewards members for engaging in health activities. The goal of Devoted Health is to create a more compassionate and accessible healthcare experience for its members.

Waltham, MassachusettsHeadquarters

2017Year Founded

$2,194.5MTotal Funding

SERIES_ECompany Stage

HealthcareIndustries

1,001-5,000Employees

Benefits

Comprehensive health plan

401(k) retirement plan

Generous vacation and holiday time

Lyra mental health resources

Time off to vote

Risks

Increased competition from Medicare Advantage providers like Clover Health and Oscar Health.

Potential regulatory changes affecting Medicare Advantage plans by CMS.

Rising healthcare costs could impact the affordability of Devoted Health's plans.

Differentiation

Devoted Health offers personalized assistance through Devoted Health Guides for member support.

The company emphasizes preventive care with its Devoted Dollars rewards program.

Devoted Health integrates virtual and in-home care with top local providers.

Upsides

Devoted Health raised $287 million in Series E funding in 2024.

The company expanded Medicare Advantage plans to eight new states in 2023.

Devoted Health achieved a 5-star Medicare Advantage rating in Ohio in 2023.

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