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.
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