Job Description

A bit about this role:

We’re seeking a Principal Claims SME to serve as a critical individual contributor and our lead expert on all claims-related policy matters. This role is a unique blend of deep, hands-on claims analysis and strategic payment policy leadership. You will be the primary point of contact for complex claims issues, using your expertise to influence providers, lead key committees, and ensure our policies are

compliant, fair, and operationally sound. This is not a management role, but it requires significant leadership and influencing skills to drive impact across the organization. You'll be expected to work with a high degree of autonomy, serving as a trusted advisor to national health systems and internal teams including executive leadership.

Your Responsibilities and Impact will include:

• Interface directly with providers, particularly health systems, on claims policies and claims

• disputes. It’s critical that the SME can clearly communicate the most complex claims to both

• experts and non-experts.

• Lead our Payment Policy Committee (PPC) and serve as our lead expert on claims and

• payment regulations, offering policy and implementation recommendations that are

• compliant and balance commercial, relationship, and operational goals

• Serve on our Contract Committee and review all provider contracts brought to Committee,

• flagging any non-favorable, vague, non-compliant, or operationally unfeasible payment

• terms.

• Review complex claims, making clear and reasonable adjudication decisions while also

• setting policy and precedence for other similar claims

Required skills and experience:

• 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, where you tackled the most complex reimbursement challenges. You’re the go-to expert for others seeking solutions.

• 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); you not only understand the rules but also the intricate interplay between coding, provider billing, and payor policy that drives accurate payment and revenue integrity.

• Outstanding communication skills and linear thinking. Your writing and your presentations are polished, substantive, and first and foremost drive clarity for a variety of audiences.

• Must have executive presence and be exceptional at influencing and building credibility and trust.

• Facile with technology; must be able to learn our tech system and be able to independently interpret claims, pull reports, run analyses.

• AI and automation proficiency with curiosity about emerging technologies. Ability to leverage AI tools for claims reviews, contract reviews, policy research.

• Fast-paced self starter. Ability to respond quickly to inbound work while also proactively identifying opportunities to improve our claims payment accuracy.

• Comfortable operating in both leadership and execution roles.

• Demonstrated leadership impact and collaborative excellence.

#LI-Remote
#LI-DS1

Salary range: $250,000 - $300,000 annually

Our ranges are purposefully broad to allow for growth within the role over time. 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 may 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.

Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce.

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!

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

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor 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.