[Remote] Senior Assistant Vice President - Healthcare Claims AI - Technical Product Leader

Note: The job is a remote job and is open to candidates in USA. EXL is a leading data analytics and digital operations company, seeking a Senior Assistant Vice President - Healthcare Claims AI - Technical Product Leader. The role involves owning the vision, strategy, and delivery of AI-powered products in healthcare claims, leading cross-functional teams to create innovative solutions that enhance operational efficiency and improve outcomes for national payers.

Responsibilities

• Define, own, and evolve the AI product roadmap for healthcare claims solutions—spanning claims adjudication automation, claims adjustment, payment integrity, COB/subrogation, provider issue resolution, and FWA detection
• Translate complex claims operational challenges into AI-first product strategies with clear business cases, ROI frameworks, and measurable KPIs (e.g., auto-adjudication rate, denial accuracy, overpayment recovery yield)
• Drive solutions from ideation → POC → MVP → production scale, using agile execution and business-centric prioritization
• Maintain a competitive landscape matrix and continuously benchmark against market players (Optum/Change Healthcare, Cotiviti, Cognizant TriZetto, HealthEdge, Conduent, etc.) to inform differentiation strategy
• Partner with sales, finance, and leadership to determine pricing, packaging, and go-to-market approach (managed services, SaaS, outcome-based/gainshare models)
• Drive the transition from traditional rules-engine claims processing to AI-augmented adjudication—automating claim edits, benefit configuration interpretation, provider contract parsing, and payment rule application
• Design reusable AI components and platform capabilities (e.g., claims document intelligence, EOB/remittance parsing, provider contract extraction, coding validation engines, browser/desktop automation agents)
• Write clear product requirements documents (PRDs), user stories, and technical specifications with well-defined acceptance criteria for engineering teams
• Champion explainability-first AI design, ensuring all models produce audit-ready, evidence-grounded outputs suitable for SIU investigations, CMS audits, and payer compliance reviews
• Apply deep knowledge of end-to-end claims operations—claim intake, edits, adjudication, pricing, payment, adjustment, appeals, grievances, provider disputes, and overpayment recovery—to identify high-impact AI use cases
• Embed AI solutions into core claims platforms and systems (QNXT, Facets, Amisys, HealthRules Payer, CSC/DXC, etc.) through platform-agnostic integration and API-first design
• Design AI-driven solutions covering pre-pay and post-pay analytics, DRG validation, code editing (CPT/ICD-10/HCPCS), duplicate claim detection, and provider billing pattern analysis
• Build cross-payer intelligence capabilities that leverage anonymized, aggregated claims data to drive payment accuracy benchmarks, denial pattern optimization, and cost-of-care insights
• Support RFP/RFI responses, orals preparation, and executive presentations for national payer pursuits
• Develop AI-powered provider operations solutions—automated provider issue resolution, correspondence generation, contract interpretation, and fee schedule management
• Serve as the product spokesperson and AI SME in client engagements—leading executive presentations, POC demonstrations, workshops, and roadmap discussions with CXO/EVP/VP stakeholders at national payers
• Partner with account management and business development teams to shape differentiated claims AI solutions for complex, enterprise-level healthcare pursuits
• Build and deliver compelling thought leadership content—white papers, case studies, conference presentations, and analyst briefings—that position EXL as a leader in claims AI innovation
• Represent EXL at industry conferences (AHIP, HCCA, SIU conferences, RISE, etc.) through presentations, panel discussions, and live product demonstrations
• Lead, mentor, and develop a high-performing team of AI engineers, product managers, data scientists, and solution architects focused on claims AI
• Foster a culture of innovation, collaboration, accountability, and continuous learning within the team
• Collaborate with offshore engineering and delivery teams to ensure timely, secure, and scalable implementation
• Build and scale an AI Center of Excellence for healthcare claims, establishing reusable agent frameworks, governance playbooks, and best practices
• Champion privacy-first design, data anonymization, and compliance with HIPAA, PHI/PII handling, and payer-specific data governance frameworks
• Ensure all AI solutions meet scalability, security, auditability, and operational excellence requirements for regulated healthcare claims environments
• Establish governance-grade AI controls including model monitoring, bias detection, drift management, and human-in-the-loop override mechanisms for claims decisioning
• Maintain compliance with CMS, state DOI regulations, NAIC guidelines, and payer-specific audit requirements for claims processing and payment integrity

Skills

• 15+ years of progressive experience in AI/ML engineering, technical product management, or platform product leadership roles
• 5+ years of leadership experience in healthcare claims technology, payer claims operations, or health-tech product organizations focused on claims/PI
• Proven track record of building and scaling AI solutions for claims processing, payment integrity, or provider operations—from POC to production at an enterprise scale
• Experience with large-scale payer claims engagements ($25M+ in managed services or technology contracts) and familiarity with FTE-to-AI transformation models in claims shops
• Bachelor's degree in computer science, Engineering, Data Science, or related technical field. Master's degree (M.Tech / MS / MBA) is strongly preferred
• Hands-on and architectural expertise in LLMs, embeddings, vector search, prompt engineering, and RAG pipelines
• Proficiency with cloud AI platforms: Azure OpenAI, AWS Bedrock (Claude, Sonnet), GCP Vertex AI
• Experience with agent orchestration frameworks: LangChain, LangGraph, CrewAI, AutoGen, or equivalent Agentic AI frameworks
• Strong understanding of MCP (Model Context Protocol), A2A protocols, and multi-agent system design
• Familiarity with browser/desktop automation tools (Playwright, Selenium) as AI agent execution layers for legacy claims system navigation
• Familiarity with secure API design, OAuth2/JWT, enterprise integration patterns, and EDI transaction sets (X12 837/835/270/271/276/277)
• Deep understanding of end-to-end healthcare claims operations: claim submission, edits, adjudication, pricing, payment, adjustment, appeals, grievances, and overpayment recovery
• Strong knowledge of pre-pay/post-pay review, DRG validation, CPT/ICD-10/HCPCS code editing, COB, subrogation, and FWA detection methodologies
• Experience with claims processing platforms and systems (QNXT, Facets, Amisys, HealthRules Payer, CSC/DXC) and provider data management
• Understanding of healthcare financial models: PMPM, total cost of care, provider reimbursement methodologies (fee-for-service, value-based, capitation), and gainshare/outcome-based pricing structures
• Familiarity with CMS regulations, state DOI requirements, NAIC model acts, and payer audit/compliance frameworks relevant to claims processing
• Exceptional executive communication skills—ability to present AI strategy and business impact to C-suite audiences (CEO, President, COO) at national payer organizations
• Proven ability to influence cross-functional stakeholders across engineering, delivery, sales, and claims operations teams
• Experience leading distributed, global teams (US + offshore) in fast-paced, high-growth environments
• Strong storytelling ability—translating complex AI capabilities into clear business value, ROI narratives, and claims transformation roadmaps
• Experience building or leading AI Centers of Excellence or reusable agent frameworks specifically for claims processing or payment integrity
• Patent holder, published researcher, or recognized speaker in the AI/healthcare claims innovation space
• Experience with document intelligence and IDP platforms for claims-related documents (EOBs, remittance advice, provider contracts, fee schedules)
• Deep familiarity with healthcare data standards: HL7, FHIR, X12 EDI (837/835/270/271/276/277), NCPDP for pharmacy claims
• Experience with Databricks, Snowflake, or similar data platforms in healthcare claims analytics context
• Background in consulting or managed services delivery for large payer claims operations
• Knowledge of competitive landscape including Optum/Change Healthcare, Cotiviti, Cognizant TriZetto, HealthEdge, Conduent, Gainwell Technologies, and emerging AI-native claims startups
• Certified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AHFI), or similar claims/PI certifications a plus

Company Overview

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