Director, Member Status - Strategy & Operations

Job Description

A bit about this role:

At Devoted, our mission is to dramatically improve the health and well-being of our members by treating each of them like family. Getting a member’s record right is part of that promise. When we carry the wrong primary payer, miss a hospice election, or have a stale address on file, the member feels it before it shows up in a report. Doing this work well is an important part of making sure members can rely on us for the care they need

We are seeking a leader to serve as the Director of Membership Status Operations. This role owns the member status conditions that determine what CMS and our state partners pay us once enrollment is complete,along with the reconciliation and controls that make those determinations reliable. The role pairs regulatory expertise with financial and operational discipline, managing these conditions as a dynamic portfolio in which an undetected or late determination can create downstream disruption for the member and keep us from delivering the seamless experience we expect.

Membership Operations has built real capability in reconciliation: confirming that every member we are responsible for is enrolled correctly and at the right effective date and rate given the information available at point of application. You will own the next stage of that work. Several of these areas are still immature, and your first job is to be honest about which ones and to build the durable, monitored, auditable operation they require. The objective is accuracy in both directions — payment that reflects the member’s true status, whether that means we are owed more or owe money back. You will directly engage with AI-enabled tools to optimize signal detection, document review, and investigation triage.

This is foundational work - and there is a meaningful opportunity for this leader to leave their fingerprints all over how we do it.

Your Responsibilities and Impact will include:

Member Status Determinations

• Own the end-to-end operation for each area: from identifying a potential issue, to investigating it, making the right determination, submitting any required updates, checking the work for accuracy, and making sure any follow-up action gets completed.

• Manage these areas with clear daily and weekly checks so we catch important status changes as they happen, rather than finding them after the fact.

• Take direct ownership of the workflows that are not yet mature, and prioritize improvements based on member impact, financial risk, and compliance risk - not just what is easiest to fix.

• Keep the operation current with CMS technical guidance, including Medicare Secondary Payer rules, hospice and ESRD payment treatment, and county-based rate structures.

• Maintain the policies that define what makes a suspect, what evidence substantiates a determination, and how it is documented, so any determination can be reproduced on demand for a CMS program audit, state review, or internal audit. Report accuracy misses that reduce revenue with the same rigor as those that increase it.

• Use AI and other tools to make these workflows more efficient, including identifying potential issues earlier and reducing manual review where it makes sense.

• Set, monitor, and enforce SLAs and KPIs across internal teams, offshore partners, and external vendors.

Reconciliation and Controls

• Define and deliver the KPIs that measure the operation — detection coverage, open inventory aging, signal-to-determination cycle time, rework, retroactive adjustment rates — and make them visible in executive-facing dashboards alongside recovered and at-risk revenue and outstanding variances.

• Run expected-vs-actual analysis to flag macro-level payment degradation early and direct remediation to the conditions driving it.

• Convert manual detection and correction into documented, owned controls with defined thresholds, aging limits, and escalation paths, so the operation does not depend on individual heroics or tribal knowledge.

• Partner with Data Science and Engineering to identify key measurement points and prioritize platform improvements, writing the business cases and holding delivery partners to committed outcomes.

• Work closely with Finance, Actuarial, Risk Adjustment, Compliance, and Legal to make sure the work is accurate, well documented, and ready for review — and to help partners understand the impact of issues when they arise.

• Build, develop, and retain the team, and bring an end-to-end perspective to policy and procedure decisions across Membership Operations.

Required skills and experience:

• Proven operator with a track record of turning complex operational problems into scalable, practical business processes.

• Demonstrated experience building operational controls where none existed, not only running a mature process at scale.

• Proven ability to take new cross-functional initiatives from idea to launch across multiple stakeholder groups.

• Able to digest intricate regulatory or technical guidance and translate it into determination criteria, evidence standards, and daily workflow.

• Fluency working with data: you can specify requirements, interrogate a dataset, and challenge a number without waiting for analyst support.

• High ethical standards and sound judgment under revenue pressure, including the willingness to surface and correct an error that goes against our financial interest.

• Comfortable owning an ambitious goal in an ambiguous, fast-moving environment — you own the determinations, the standards, the controls, and the roadmap, and you build the case when the work needs new investment.

Desired skills and experience:

• Experience managing multiple teams and vendors, including offshore partners.

• Prior experience in Medicare Advantage, D-SNP, or integrated Medicare-Medicaid experience, including state file reconciliation and deeming administration.

• Experience operating under CMS program audit or comparable regulatory examination.

• Proven organizational, communication, and leadership skills.

Remote with onsite expectations multiple times per year.

#LI-Remote
 

Salary Range: $182,000-$216,000 / year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium

• Generous paid time off

• $100 monthly mobile or internet stipend

• Stock options for all employees

• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles

• Parental leave program

• 401K program

• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience.

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.