Senior Assistant Vice President - Healthcare Claims AI - Technical Product Leader

Product Development-Product Development

Healthcare Claims AI / Technical Product Leader to own the vision, strategy, and delivery of AI-powered products and solutions across the healthcare claims lifecycle. This role sits at the intersection of product strategy, AI engineering leadership, and healthcare claims domain expertise—spanning claims adjudication, claims adjustment, payment integrity (PI), coordination of benefits (COB), subrogation, provider dispute resolution, and fraud/waste/abuse (FWA) detection.

You will lead cross-functional teams to architect, build, and operationalize Agentic AI and Generative AI solutions that create measurable value—reducing claims processing costs, accelerating adjudication turnaround, improving payment accuracy, strengthening audit outcomes, and modernizing provider operations workflows. This is a high-visibility leadership role ideal for someone passionate about combining technology, healthcare claims depth, and design thinking to create lasting business impact for national payers.

Responsibilities

AI Product Strategy & Roadmap Ownership

• 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).

Technical & AI Engineering Leadership

• 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.

Healthcare Claims Domain & Operational Transformation

• 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.

Client Engagement & Thought Leadership

• 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.

Team Leadership & Talent Development

• 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.

Governance, Compliance & Risk Management

• 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.

Qualifications

Experience

• 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.

Technical Skills

• 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).

Domain Skills

• 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: PM