Job description
Job Summary
Alivi is seeking a Lead Software Developer with deep healthcare payer domain expertise to join our CapAdmin platform team, our proprietary claims administration system supporting our TPA (Third-Party Administrator) operations. This is a hybrid technical-SME leadership role designed to bridge the gap between engineering execution and payer / claims business knowledge. The ideal candidate is a senior developer who has lived inside a payer or TPA platform someone who understands not just how to build software, but how claims, eligibility, capitation, COB, UM, and UB04 workflows actually function in a real payer environment. This role will directly support our CapAdmin Development Lead, owning architecture, requirements validation, and SME-level guidance ensuring features are built right the first time, with complete domain requirements captured before development begins.
Duties & Responsibilities
3.1 Healthcare Payer Domain Leadership (Primary Focus)
Serve as the internal SME for payer / TPA workflows, including:
UB04 / CMS-1500 institutional and professional claim form processing
Coordination of Benefits (COB) — primary, secondary, tertiary payer logic
Utilization Management (UM) — prior authorization, medical necessity, concurrent review integrations
Capitation models — PMPM calculations, cap reconciliation, risk pool accounting, sub-cap arrangements
Eligibility & enrollment (834 transactions)
Claims adjudication rules, edits, and pricing logic
EDI standards: 837, 835, 270/271, 276/277, 278
Translate complex payer business requirements into clear, complete technical specifications before development begins. Partner with Operations, Finance, and Compliance to validate claims and capitation logic end-to-end.
3.2 Technical Leadership
Partner with the CapAdmin Development Lead to drive architecture, scalability, and platform modernization.
Lead code reviews with a domain lens — catching not just code quality issues but business logic errors.
Mentor mid-level developers on healthcare payer concepts they may not have prior exposure to.
Contribute to design and implementation of new product line integrations (Ophthalmology, expanded COB, etc.).
3.3 Requirements & Quality Ownership
Own the "requirements completeness" function — ensuring every feature has full payer-domain context before sprint commitment.
Work directly with Business Analysts, QA, and Product to eliminate the root cause of most CapAdmin defects: incomplete requirements.
Define and document acceptance criteria grounded in payer regulations and customer contracts.
3.4 Cross-Functional Collaboration
Partner with Operations leadership on claims accuracy, capitation reconciliation, and customer-facing escalations.
Support customer-facing technical conversations with payer clients (Sunshine Health, Humana, etc.) when domain expertise is needed.
Collaborate with the Architecture, Security, and Data / BI teams on enterprise alignment.
Requirements
4.1 Healthcare Payer / TPA Experience (Non-Negotiable)
6+ years working inside a payer platform, TPA system, or claims administration software (e.g., Facets, QNXT, HealthRules, HealthEdge, TriZetto, EZ-CAP, or proprietary platforms).
Hands-on experience with:
· UB04 and CMS-1500 claim processing
COB rules and logic (NAIC order of benefits, Medicare secondary payer)
· Utilization Management workflows
· Capitation models and reconciliation
EDI transactions (837, 835, 834, 270/271, 278)
Working knowledge of CPT, HCPCS, ICD-10, revenue codes, and place-of-service codes.
Familiarity with CMS, state Medicaid, and commercial payer requirements.
4.2 Technical Experience
6+ years of professional software engineering experience.
Strong proficiency in C# / .NET, Java, or similar enterprise languages.
Solid experience with relational databases (SQL Server, PostgreSQL) and data modeling for claims / payer systems.
Experience with REST APIs, microservices, and integration patterns.
Familiarity with AWS (Redshift / AWS / QuickSight stack) is a strong plus.
Comfortable with Agile / Scrum, CI/CD, and modern DevOps practices.
4.3 Leadership & Communication
Demonstrated ability to mentor engineers and translate domain knowledge across technical and business audiences.
Strong written and verbal communication — able to participate in customer and executive-level conversations.
Bilingual (English / Spanish) Spanish is a must.
5. Preferred Qualifications
Prior experience at a TPA, MSO, IPA, or health plan in a technical leadership role.
Experience with specialty benefits administration (vision, transportation, podiatry & therapy etc.).
Familiarity with HITRUST, HIPAA, and HITECH compliance requirements for payer systems.
Experience supporting Medicaid managed care (e.g., Sunshine Health, Humana, Florida Medicaid).
Background in risk-based contracts, sub-capitation, and value-based care arrangements.
Originally posted on Himalayas
Who can apply
Eligible countries: United States. Accepted UTC offsets: UTC-10, UTC-9, UTC-8, UTC-7, UTC-6, UTC-5, UTC+14. Review the full description for employer-specific work authorization, residency and schedule requirements.