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We're committed to bringing passion and customer focus to the business.
Experience: 610 years (techno-functional)
Domain: Medical claims adjudication, edits, payment integrity, denials management
About The Role
Own end-to-end problem solving for claims operations: improve auto-adjudication, reduce rework/denials, and modernize integrations. Partner with business, data, and engineering to deliver measurable gains in first-pass adjudication, throughput, and cost-per-claim.
Key Responsibilities
- Consulting & Value Realization
- Lead discovery workshops and quantify value (autoadjudication %, FPY, rework minutes)
- Define roadmaps, KPIs, operating models, and change plans
- Claims Domain Execution
- Analyze adjudication rules, code edits, COB, pricing, bundling/unbundling, medical policy application
- Design/process 837 (I/P/D) and 835 flows; integrate with payment integrity and audit
- Reduce denial drivers; align reconsideration/appeal handoffs with provider outreach
- Interoperability & Data
- Design EDI X12 interfaces (837/835/276/277) and FHIR-based APIs where relevant
- Define data quality controls, lineage, and auditability
- Automation & AI
- Identify automations (edits tuning, rules orchestration, exception triage)
- Apply GenAI/NLP for denial reasoning extraction and claim note summarization with HITL
- Governance & Delivery
- Backlog management, UAT, benefits tracking, and executive readouts
MustHave Qualifications
- Experience: 610 years in US healthcare consulting/solution delivery across payers and/or providers.
- Domain Depth: Handson with claims adjudication, Membership/prior auth, care management.
- Compliance: Working knowledge of HIPAA Privacy/Security, PHI/PII handling, audit readiness, data governance.
- TechnoFunctional: Ability to translate business needs into technical designs across cloud, data, APIs, and interoperability.
- GenAI/Analytics: Practical experience with GenAI solutioning (e.g., RAG, prompt engineering, evaluation) and classical analytics (segmentation, anomaly detection).
- Cloud/Data Tools: Exposure to Azure/AWS/GCP, Snowflake/Databricks/BigQuery, SQL/PySpark, ETL/ELT (ADF/Glue), APIs (REST/GraphQL), Kafka.
- Consulting & BA: Proven proposal/RFP experience, SOW/MSA inputs, stakeholder management, requirements elicitation, UAT planning.
- Communication: Executive storytelling, workshop facilitation, and crossfunctional influence.
Preferred Qualifications
- Experience with payment integrity, DRG/APC/fee schedules, pricing engines
- Exposure to cloud data platforms (Azure/AWS/GCP), Snowflake/Databricks, and BI (Power BI/Tableau)
- GenAI/RAG exposure for claims documentation and knowledge retrieval
- Certifications: AHIP, X12/FHIR, HIPAA, Azure/AWS/Databricks
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
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