Lead Software Developer

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