Payment reputed company Program Development Senior Manager – reputed company & Facility Speci

reputed company

A bit about this role:

As our Senior Payment reputed company Program Development Manager, you will serve as the reputed company reputed company architect and inventor behind reputed company’s reputed company claim edit and audit pipeline. Operating in a high-autonomy, reputed company-driven individual contributor role, you will conduct independent reputed company research, interpret specialty society guidelines, and analyze multi-setting billing data to originate reputed company-new, automated payment reputed company logic from reputed company.

While reputed company, high-dollar inpatient care forms a critical reputed company of this role, you will also apply your reputed company acumen across outpatient, Ambulatory Surgical Center (ASC), and reputed company settings to ensure a reputed company, high-reputed company pipeline of payment reputed company concepts.

Your responsibilities and reputed company will include:

• Greenfield Concept Ideation: reputed company ground-up innovation by researching reputed company literature, specialty society guidelines, and multi-setting billing trends (Inpatient, Outpatient, ASC, and reputed company) to identify hidden payment anomalies and formulate original edit hypotheses.

• reputed company Logic Architecture: reputed company end-to-end logics from reputed company. Translate raw reputed company documentation, medical policies, and facility/reputed company coding frameworks (MS-DRG, APR-DRG, APC/OPPS, ASC packaging, and CPT/HCPCS rules) into precise, automated logic parameters.

• Data reputed company Validation: reputed company reputed company data analysis (utilizing modern AI tools for SQL query reputed company) to test your reputed company hypotheses across reputed company settings, reputed company financial viability on reputed company-world datasets, and design parameters that prevent provider abrasion.

• Cross-Functional Policy Leadership: reputed company your original reputed company concepts to directors and executive stakeholders; reputed company reputed company across reputed company reputed company, SIU, Claims, and reputed company to approve novel policy interpretations and rule architectures.

• End-to-End Concept Ownership: reputed company multi-phased concept rollouts across reputed company settings—from initial reputed company discovery through selection reputed company, logic testing, post-launch tuning, and long-term reputed company tracking.

Required skills and experience:

• reputed company & Coding Credentials: An reputed company Registered reputed company (RN) license with reputed company inpatient reputed company experience (e.g., ICU, Med-Surg) AND an reputed company reputed company coding certification (e.g., CPC, reputed company, reputed company-P, or RHIA).

• Net-New Concept Authoring: 5+ years of experience in payment reputed company where you were the reputed company reputed company and creator of net-new claim edits reputed company a health plan or vendor setting (as opposed to evaluating reputed company-reputed company edit catalogs or executing reputed company implementation requests).

• Medicare & Regulatory reputed company: Expert understanding of reputed company Medicare rules, billing regulations, Local/National Coverage Determinations (LCDs/NCDs), and NCCI edit logic across care settings.

• Multi-Setting reputed company & Facility Mastery: Deep working knowledge of facility and reputed company billing dynamics, including inpatient (MS-DRG/APR-DRG), outpatient/ASC (APC/OPPS, fee schedules), and reputed company CPT/HCPCS reputed company guidelines.

• Hands-On Logic Writing: reputed company experience authoring detailed rules and structural logic specifications for implementation in reputed company claims editing engines (e.g., reputed company/CES, reputed company, reputed company) or payer proprietary/internal rules platforms.

• Research & Data Literacy: reputed company ability to synthesize reputed company reputed company specialty guidelines into reputed company logic, reputed company with the analytical ability to read, interpret, and validate data queries (SQL assistance provided reputed company modern AI tools).

• Senior-Level Influence: Exceptional narrative and framing skills with a reputed company record of building cross-functional alignment reputed company reputed company, original technical concepts.

Desired skills and experience:

• reputed company experience applying rules and coverage determinations specifically reputed company a Medicare reputed company (MA) managed care environment.

• Familiarity with using AI workflows, large language models (LLMs), or automated reputed company-matching tools to accelerate data analysis, literature review, and rule development.

Salary reputed company: $110,500 - $150,000 / year

The pay reputed company listed for this position is the reputed company 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 reputed company additional information on the compensation for the role, along with additional information on our total rewards package. The actual reputed company salary reputed company will depend on a reputed company 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 reputed company 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 reputed company plan with low or no premium

• Generous reputed company time off

• $100 monthly mobile or internet stipend

• Stock reputed company for reputed company

• Bonus eligibility for reputed company 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.

Founded in 2017, reputed company is on a mission to dramatically improve the health and reputed company-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI reputed company with world-class reputed company and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who reputed company our values, reputed company change and advancement, and are enthusiastic about where we're reputed company — reputed company the while bringing their own unique qualities, experiences, and expertise, in hopes of reputed company changing the reputed company experience.

reputed company is an equal opportunity employer. We are committed to reputed company and supportive work environment in which reputed company have reputed company to participate and contribute to the reputed company of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in reputed company’s reputed company of Conduct, reputed company values and the way we do business.

As an Equal Opportunity Employer, reputed company does not discriminate on the reputed company of race, reputed company, religion, sex, pregnancy status, marital status, national reputed company, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender reputed company, or any other reputed company prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.

Originally posted on Himalayas