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About the Role
Alivi is seeking a Lead Software Engineer with deep healthcare payer domain expertise to join our CapAdmin platform team. This hybrid role bridges engineering execution and payer/claims business knowledge, focusing on architecture, requirements validation, and SME guidance for claims administration.
Responsibilities
- Serve as the internal SME for payer / TPA workflows, including UB04 / CMS-1500 claim processing, Coordination of Benefits (COB), Utilization Management (UM), Capitation models, Eligibility & enrollment, Claims adjudication rules, and EDI standards.
- Translate complex payer business requirements into clear, complete technical specifications.
- Partner with Operations, Finance, and Compliance to validate claims and capitation logic.
- Partner with the CapAdmin Development Lead to drive architecture, scalability, and platform modernization.
- Lead code reviews with a domain lens, identifying business logic errors.
- Mentor mid-level developers on healthcare payer concepts.
- Contribute to the design and implementation of new product line integrations.
- Own the 'requirements completeness' function, ensuring full payer-domain context before sprint commitment.
- Work with Business Analysts, QA, and Product to eliminate defects caused by incomplete requirements.
- Define and document acceptance criteria grounded in payer regulations and customer contracts.
- Partner with Operations leadership on claims accuracy, capitation reconciliation, and customer-facing escalations.
- Support customer-facing technical conversations with payer clients.
- Collaborate with Architecture, Security, and Data / BI teams on enterprise alignment.
Requirements
- 6+ years working inside a payer platform, TPA system, or claims administration software.
- Hands-on experience with UB04 and CMS-1500 claim processing.
- Hands-on experience with COB rules and logic.
- Hands-on experience with Utilization Management workflows.
- Hands-on experience with Capitation models and reconciliation.
- Hands-on experience with 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.
- 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.
- Demonstrated ability to mentor engineers and translate domain knowledge across technical and business audiences.
- Strong written and verbal communication skills.
- Bilingual (English / Spanish) is a must.
Skills
- Healthcare Payer Domain Expertise
- Claims Administration
- UB04 / CMS-1500 processing
- Coordination of Benefits (COB)
- Utilization Management (UM)
- Capitation models
- Eligibility & enrollment
- EDI standards (837, 835, 834, 270/271, 278)
- C# / .NET
- Java
- SQL Server
- PostgreSQL
- Data Modeling
- REST APIs
- Microservices
- Agile / Scrum
- CI/CD
- DevOps
- Technical Leadership
- Code Reviews
- Mentoring
- Requirements Gathering
- Technical Specifications
- Cross-Functional Collaboration
- Customer Support
- Spanish
Location
- Hybrid
Work Type
- Hybrid
Experience Level
- 6+ years of healthcare payer/TPA experience
- 6+ years of software engineering experience
About the Company
- Alivi is a company focused on claims administration through its proprietary system, CapAdmin, supporting TPA operations.