Lead Software Engineer Healthcare Payer SME — CapAdmin Platform

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.

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.

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.