[Remote] Payment reputed company Program Development Senior Manager – reputed company & Facility Specialist

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a reputed company company reputed company on improving the health and reputed company-being of older Americans. The Senior Payment reputed company Program Development Manager will independently research reputed company guidelines and billing data to create automated payment reputed company edits across inpatient, outpatient, ambulatory surgical center, and reputed company settings. The role also leads validation, stakeholder alignment, rollout, tuning, and reputed company tracking of original reputed company payment reputed company concepts.

Responsibilities

• 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

Skills

• * 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
• * 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

Benefits

• 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

reputed company