Lead Software Engineer Healthcare Payer SME - CapAdmin Platform

Job Summary

Alivi is seeking a Lead Software Engineer 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 engineer 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)

• 7+ 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

• 8+ 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) is a plus given our Miami-based team.

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.