Senior Claims Optimization Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Proactively Identify Friction: Independently conduct in-depth data analysis across intricate claims databases to pinpoint operational friction, inefficiencies, handoff challenges, and sources of waste or leakage that are prime candidates for automation.

• Develop Advanced Automations: Create and implement production-quality scripts (using Python, R, or advanced RPA platforms) that can interface with multiple systems through APIs for managing bulk claims adjustments and safe auto-adjudication processes.

• Spearhead AI & Prompt Engineering: Take charge of the operational rollout and optimization of generative AI and agentic workflows. You will design and evaluate the prompts that enable AI to accurately process claims, provider appeals, and medical records to enhance cycle times.

• Safeguard the Ecosystem: Oversee automated scripts and bots in relation to upstream system updates or configuration modifications, ensuring uninterrupted operation in our automated production workflows.

• Collaborate Cross-Functionally: Convert complicated operational obstacles into clear, technical requirements when working with core Engineering, while interpreting the technical impacts of automation for Claims leadership in accessible language.

• Manage Comprehensive Delivery: Oversee the UAT (User Acceptance Testing) process, deployment strategy, and post-launch oversight for large-scale automation projects, ensuring that solutions achieve the desired outcomes.

⛳️ Requirements

• 5+ years of progressive experience in healthcare operations analytics, process engineering, or automation delivery.

• Advanced proficiency in SQL coupled with a strong capability in writing production-ready Python or similar scripting languages that interact with APIs and databases.

• Demonstrated success in implementing automation frameworks along with a keen interest or practical experience in utilizing LLMs/AI to alleviate operational bottlenecks or derive structured information from unstructured data.

• Comprehensive understanding of claims adjudication systems, claim routing logic, and the influence of a Payment Integrity program on downstream provider dispute workflows.

• You thrive without a roadmap. You can take an ambiguous executive challenge (e.g., "Our adjustment inventory is increasing") and independently deliver a data-supported root cause analysis along with a functional automation tool to resolve it.

🏝️ Benefits

• Alternative medicine coverage

• Flexible PTO

• Up to 16 weeks paid parental leave

• Paid holidays

• 401k program

• Transportation perks

• Education reimbursement

• 2 days of paid paw-ternity leave