软件开发负责人
Lead Software Developer
职位概述
Alivi 正在寻找一位具备深厚医疗保险公司领域专业知识的高级软件开发人员，加入我们的 CapAdmin 平台团队，我们的专有理赔管理系统的支持我们第三方管理员（TPA）运营。这是一个结合技术与领域专家的领导角色，旨在弥合工程执行与保险公司/理赔业务知识之间的差距。理想的候选人是一位资深开发人员，曾深入参与过保险公司或 TPA 平台，不仅懂得如何构建软件，更了解理赔、资格验证、定额支付、利益协调（COB）、使用管理（UM）和 UB04 流程在真实保险公司环境中的运作方式。该职位将直接支持我们的 CapAdmin 开发负责人，负责架构设计、需求验证和领域专家级别的指导，确保功能在第一次开发时就正确完成，并在开发开始前完整捕捉所有领域需求。
职责与要求
3.1 医疗保险公司领域领导（主要职责）
作为内部保险公司/TPA 流程的专家，包括：
- UB04 / CMS-1500 机构和专业理赔表处理
- 利益协调（COB）—— 主要、次要、第三支付方逻辑
- 使用管理（UM）—— 预先授权、医疗必要性、并行审查集成
- 定额支付模型 —— 每人每月费用（PMPM）计算、定额对账、风险池会计、子定额安排
- 资格验证与注册（834 交易）
- 理赔审核规则、编辑和定价逻辑
- EDI 标准：837、835、270/271、276/277、278
在开发开始前，将复杂的保险公司业务需求转化为清晰、完整的技术规范。与运营、财务和合规部门合作，端到端验证理赔和定额支付逻辑。
3.2 技术领导力
- 与 CapAdmin 开发负责人合作，推动架构、可扩展性和平台现代化。
- 以领域视角进行代码审查 —— 不仅发现代码质量问题，还要发现业务逻辑错误。
- 指导中级开发人员理解他们可能没有接触过的医疗保险公司概念。
- 参与新产品线集成的设计与实现（如眼科、扩展 COB 等）。
3.3 需求与质量责任
- 负责“需求完整性”功能 —— 确保每个功能在冲刺承诺前都有完整的保险公司领域背景。
- 直接与业务分析师、QA 和产品团队合作，消除 CapAdmin 缺陷的主要根源：
查看英文原文
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