Claims Configuration Senior Manager

Devoted Health • Waltham, MA

2d • $110,500 - $150,000 • Remote

About The Position

Devoted Health is hiring a Senior Manager, Claims Adjudication Logic to own the accuracy, integrity, and strategic direction of its claims back-end logic. The role serves as the subject matter expert on how claims move through the system, including the rules that determine whether claims auto-adjudicate or pend for manual review, how claims are matched to provider contracts, and how outcomes are communicated through EOBs, EOPs, and remittance advice. The position focuses on building a more accurate, automated, scalable, and cost-effective claims operation.

The Senior Manager will work with Engineering, Claims Operations, Network, Provider Operations, and Provider Services to optimize adjudication logic, resolve payment and communication issues, and create sustainable fixes. The role also establishes measurement, audit, validation, KPI, and reporting frameworks that provide leadership with confidence in claims payment outcomes, while anticipating regulatory changes, new contract structures, and emerging technology.

Devoted Health describes its mission as improving the health and well-being of older Americans by caring for everyone like family. Its integrated care platform combines data and AI access with clinical and service experiences. Devoted is an equal opportunity employer committed to a safe, supportive, diverse, and collaborative workplace.

Requirements

• At least 6 years of experience in business operations or operational leadership.
• Comfort with ambiguity and willingness to investigate complex claims system logic in depth.
• Exceptional communication skills, including the ability to explain complex claims logic to technical and non-technical audiences.
• Demonstrated success driving meaningful change and measurable operational results in fast-paced environments, with a bias toward action and continuous improvement.
• Strong analytical skills, experience building and developing KPIs, and ability to work with large claims datasets to diagnose adjudication outcomes and quantify operational and financial impact.
• Ability to thrive in a fast-paced, metrics-driven environment and prioritize and manage multiple initiatives.

Nice To Haves

• Curiosity and hands-on experience with AI tools, automation, or LLM-based workflows in operational settings.
• Knowledge of health insurance claims processing, particularly Medicare Advantage, including adjudication workflows, provider contracting, and regulatory and compliance requirements.
• Experience partnering with Engineering on rules-based systems, workflow design, or claims platform development.

Responsibilities

• Own the auto-adjudication rate as a core operational metric; evaluate flags and pend reasons for business value, accuracy, and operational cost, and work with Engineering to retire, refine, or automate existing flags and design new ones where appropriate.
• Serve as the subject matter expert on matching claims to provider contracts and contract groups, including provider identifiers, TIN/NPI relationships, network status, effective dates, and contract hierarchy.
• Identify and resolve contract-matching mismatches that lead to incorrect payments, partnering with Provider Operations and Network to align contract intent with claims processing.
• Own EOB and EOP generation logic, ensuring communications accurately reflect adjudication outcomes, member cost share, and denial or adjustment reasons.
• Ensure member-facing communications meet CMS requirements and are clear and understandable, and provider-facing communications support payment reconciliation.
• Serve as the subject matter expert on remittance outputs, including 835/ERA files and payment reconciliation; support providers, Provider Services, and Engineering in resolving remit issues and drive root-cause fixes.
• Proactively identify adjudication, matching, and communication errors; lead root cause analysis and drive sustainable fixes with Engineering, Claims Operations, and Network/Provider Operations.
• Establish and own a framework for measuring claims logic performance, including auto-adjudication rate, manual adjudication rates by reason, contract match accuracy, EOB/EOP accuracy, and remit-related provider inquiries.
• Build audits, validation testing, KPIs, and reporting that provide leadership confidence in payment outcomes.
• Recommend improvements in response to regulatory changes, new contract structures, and emerging technology to reduce manual touch, payment errors, provider abrasion, and operational risk.

Benefits

• Employer-sponsored health, dental, and vision plans with low or no premium.
• Generous paid time off.
• $100 monthly mobile or internet stipend.
• Stock options for all employees.
• Bonus eligibility for roles below Director level; commission eligibility for Sales roles.
• Parental leave program.
• 401(k) program.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed