Product Manager - Claims Pricing & Value-Based Care

nirvanaHealth is building the payer enterprise on a digital workforce. Our cloud-native Aria platform delivers payer administrative and care-continuum functions as Transaction-as-a-Service (TaaS) — combining configurable workflows, RPA, machine learning, and agentic AI across Commercial, ASO, Medicare Advantage, Medicaid, ACA, and value-based care lines of business. We are hiring a Product Manager to lead the build-out of Aria's capitation and value-based care capabilities alongside our Chief Product Officer.𝗝𝗼𝗯 𝗦𝘂𝗺𝗺𝗮𝗿𝘆This Product Manager works directly with the Chief Product Officer to build Aria's capitation and value-based care module — turning payer reimbursement models like PMPM, CMS-MMR, risk pools, and delegated-risk arrangements into platform logic, business rules, and configuration that Aria's digital workforce executes at scale. The role partners with senior engineers to convert complex pricing and claims operations into engineering-ready specifications, working across adjudication, payment integrity, and encounter submission as needed.𝗝𝗼𝗯 𝗥𝗲𝘀𝗽𝗼𝗻𝘀𝗶𝗯𝗶𝗹𝗶𝘁𝗶𝗲𝘀• Work closely with the Chief Product Officer and cross-functional partners to build pricing and reimbursement constructs—fee schedules, contracted rates, capitation (PMPM, % of Premium, CMS-MMR), DOFR, risk pool, bundled payments, and episode-based payments.• Translate claims operations into the business rules, edits, configuration, data requirements, and exception workflows that the Aria digital workforce executes.• Help define benefit configuration and provider contract configuration as consumed by the claims engine at run time, including the handoff from product, provider, and network teams.• Help define auto-adjudication strategy, claims edits, COB logic, payment integrity controls, and exception-routing logic.• Contribute to payment execution, recoupment, settlement, and claims financial reconciliation workflows, including capitation and delegated-risk execution under value-based arrangements.• Contribute to encounter submission and correction workflows, including Medicare Advantage, Medicaid, and other applicable state or federal encounter data requirements.• Partner with senior engineers and implementation teams to convert claims requirements into engineering-ready specifications, UAT plans, regression scenarios, and release-ready documentation.𝗤𝘂𝗮𝗹𝗶𝗳𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀𝗘𝗱𝘂𝗰𝗮𝘁𝗶𝗼𝗻• Bachelor's degree required; major in business, healthcare administration, technology, or a related field preferred.𝗣𝗿𝗼𝗳𝗲𝘀𝘀𝗶𝗼𝗻𝗮𝗹 𝗘𝘅𝗽𝗲𝗿𝗶𝗲𝗻𝗰𝗲• Solid understanding of pricing and reimbursement constructs—fee schedules, contracted rates, capitation (PMPM, % of Premium, CMS-MMR), DOFR, risk pool, bundled payments, and episode-based payments.• 5+ years of experience in product management, product ownership, senior business analyst, or implementation lead roles on a payer claims platform, health plan service, or core administrative processing system.• Hands-on experience with at least two of: claims adjudication, claims edits, benefit configuration, provider contract configuration, payment integrity, encounter submission.• Working knowledge of one or more payer lines of business — Medicare or Medicare Advantage preferred; Commercial, Medicaid, ACA/Exchange, or ASO/self-funded acceptable.• Demonstrated track record translating claims operations into engineering-ready requirements.𝗦𝗽𝗲𝗰𝗶𝗮𝗹𝗶𝘇𝗲𝗱 𝗦𝗸𝗶𝗹𝗹𝘀• Strong written and verbal communication; ability to translate complex adjudication logic into clear specifications and decision tables.• Working familiarity with CMS regulatory requirements relevant to claims and encounter submission.• Experience authoring SOPs and process documentation used by claims operations, payment integrity, and implementation teams.• Comfort working directly with senior engineering teams in an Agile or SAFe environment.• Comfort using generative AI tools to accelerate requirements drafting, workflow mapping, test-case generation, process documentation, and analysis. Deep prior AI experience is not required; curiosity and adaptability are.𝗧𝗲𝗰𝗵𝗻𝗶𝗰𝗮𝗹 𝗦𝗸𝗶𝗹𝗹𝘀• Comfortable reading X12 claims transaction sets (837, 835), data models, and integration specifications.• Proficient with Jira/Confluence and structured backlog management.• Strong PC skills, including MS Word, Excel, and PowerPoint.𝗔𝗱𝗱𝗶𝘁𝗶𝗼𝗻𝗮𝗹 𝗖𝗼𝗻𝘀𝗶𝗱𝗲𝗿𝗮𝘁𝗶𝗼𝗻𝘀Applicants must be able to pass a background investigation; all offers are contingent upon the successful completion of a background check per company policy.