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Job Description
Structured overview of role & requirementsAbout This Role
Create and validate golden datasets and claim scenarios to support AI/ML-driven payer operations and adjudication testing.
Manually apply benefit and adjudication rules to determine accurate claim outcomes and financial impacts, ensuring traceability and compliance.
Support model testing, agent evaluation, and AI governance by partnering with Product, Engineering, and Governance teams to standardize and QA outputs across formats (X12, JSON, Excel).
Minimum Requirements
11+ years of experience in software industry or relevant role.
5+ years experience in product management, claims operations, or payer testing/QA.
Strong payer domain knowledge including claims, benefits, prior authorization, and policy/editing logic.
Experience working with structured data formats such as X12 and JSON and performing QA on data and outcomes.
Ideal Candidate Profile
Experienced in complex payer operations and claims adjudication with hands-on knowledge of denials, call center issues, and configuration complexity.
Proven ability to translate product requirements into scalable test data and manual adjudication logic for AI/ML product evaluation.
Comfortable working in cross-functional partnerships involving Product, Engineering, and AI Governance to support evaluation and compliance processes around healthcare payer AI systems.