Job Description

A bit about this role:

As our Payment Integrity Program Development Manager you will serve as a premier coding and billing regulations expert operating in a high-autonomy, outcomes-driven Individual Contributor (IC) role. We give our managers creative liberty to design innovative concepts across the entire spectrum of prospective pre- and post-payment edits and audits. You will bridge coding and billing expertise, regulatory policy, and data analytics to transform complex guidelines into intelligent, automated payment integrity software logic

Your responsibilities and impact will include:

• Innovative Concept & Rule Development (The Crux of the Role): 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 out precise conditions, exclusions, thresholds, and flags.
• Hypothesis Testing & Data Querying: Must be capable of running data queries to prove the financial validity of a coding and billing hypothesis and authoring the resulting technical specification document. (Note: We provide modern AI tools to generate and edit SQL scripts; you do not need to be a software expert, but you must possess the ability to read, interpret, and understand data scripts to validate results and analyze proof-of-concept datasets).
• Defensible Policy & Friction Management: Design payment policies where CMS guidance needs to be supplemented to ensure defensibility in supporting the concept. Proactively anticipate downstream appeal behaviors and provider disputes to craft strong explanatory narratives within the rule design.
• Performance Optimization: Post-release, improve concept efficacy, false positives, and provider abrasion, continuously refining active rules based on real-world results and updated behavioral trends.
• AI Workflow Adoption: Use large language models (LLMs) or automated pattern-matching tools to review claim trends and develop narratives, accelerating the translation of signal into active payment logic.
• Regulatory Policy Mapping: Connect identified billing anomalies directly to published primary defense sources, including CMS guidelines, NCCI bundling frameworks, LCD/NCD rules, and AMA coding mandates.
• Project & Portfolio Management: Plan, organize, and coordinate discrete initiatives and concepts to achieve specific, measurable payment accuracy goals and deadlines. Proactively identify pipeline obstacles, problem-solve execution blocks, and implement logic adjustments to drive greater efficiency.
• Cross-Functional Alignment: Partner with PI Directors, internal auditors, SIU, and claims operations to ensure coding and billing appropriateness, regulatory compliance, and cross-functional strategic alignment.

Required skills and experience:

• 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.
• Demonstrated experience and comfort with concept development logic, including a proven track record of writing logic rules or structural guidelines for claims processing implementation.
• Demonstrated ability to plan, organize, and coordinate individual concepts and initiatives, utilizing strong problem-solving skills to clear operational obstacles and meet deadlines.
• Strong analytical literacy with the ability to read, interpret, and validate data query scripts or advanced spreadsheets to confirm edit efficacy and check coding and billing hypotheses.

Desired skills and experience:

• Preferred Certification: 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 Part D parameters and High-Cost Drugs under Part B (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

#LI-Remote

Salary Range: $73,000-$120.000 / year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.