[Remote] Principal Claims & Payments Expert at Devoted Health

United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

10+ years of Deep claims expertise with a strong understanding of U.S. healthcare, Medicare Advantage, health system ecosystem, revenue cycle management, utilization management, and payment integrity
Demonstrated mastery of claims policy and adjudication gained from extensive experience at a large-scale payer
Strong functional expertise in Medicare Advantage health plan operations, with a deep understanding of its key financial drivers, healthcare delivery systems, payment methodologies, and regulatory frameworks
Unparalleled expertise in medical coding (CPT, HCPCS Level II, ICD-10-CM/PCS); understanding of the rules and intricate interplay between coding, provider billing, and payor policy
Outstanding communication skills and linear thinking
Ability to influence and build credibility and trust
Facile with technology; ability to learn our tech system and independently interpret claims, pull reports, run analyses
Proficiency in AI and automation tools for claims reviews, contract reviews, policy research
Fast-paced self-starter with ability to respond quickly to inbound work while proactively identifying opportunities to improve claims payment accuracy
Comfortable operating in both leadership and execution roles
Executive presence and ability to leverage AI tools for claims reviews, contract reviews, policy research
Ability to work with a high degree of autonomy, serving as a trusted advisor to national health systems and internal teams including executive leadership

Responsibilities

Interface directly with providers, particularly health systems, on claims policies and claims disputes
Lead our Payment Policy Committee (PPC) and serve as our lead expert on claims and payment regulations
Review complex claims, making clear and reasonable adjudication decisions while setting policy and precedence for other similar claims
Flag any non-favorable, vague, non-compliant, or operationally unfeasible payment terms
Review all provider contracts brought to Committee, flagging any non-favorable, vague, non-compliant, or operationally unfeasible payment terms
Lead our Contract Committee and review all provider contracts brought to Committee

Skills

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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