Principal AI Engineer - Healthcare startup

Principal AI Engineer

AI-Native Engineering | Hands-On Technical Leadership | Healthcare | Remote US

$175-275k base + bonus + equity

This isn't a Principal Engineer role where you spend your week in meetings and architecture reviews.

We're partnered with a fast-growing healthtech company looking for an exceptional Principal Engineer who still wants to spend the majority of their time building.

They're looking for someone who is already deeply AI-native: using multiple coding agents every day, orchestrating them across complex engineering tasks, critically reviewing their output, and using AI as a genuine force multiplier without compromising engineering quality.

You'll have significant influence over architecture and technical direction, but you'll also design, code, test, ship and support your own systems in production.

The Opportunity

The company is building an AI-powered healthcare platform that helps providers improve patient engagement, orchestrate care journeys and automate complex clinical workflows.

Their technology is co-developed with leading health systems and deployed into live clinical environments, giving engineers direct feedback on how what they build impacts providers and patients.

As a Principal Engineer, you'll help define how the platform evolves technically while remaining deeply involved in building it.

You'll own core backend services end-to-end, generate and prototype new product ideas, design scalable systems and help establish what world-class AI-native software engineering looks like as the company grows.

What You'll Be Doing

• Spend the majority of your time coding and shipping production software
• Own complex products and services from technical design through production
• Build scalable, event-driven backend systems using Python, FastAPI, PostgreSQL and Kafka
• Design and ship agentic AI systems, including tool/function calling, multi-step workflows, RAG and MCP
• Use AI coding agents throughout the development lifecycle to dramatically increase engineering velocity
• Maintain a high bar for architecture, correctness, security, testing and maintainability
• Develop robust LLM evaluation strategies using tools such as Promptfoo and LangSmith
• Own services in AWS, including deployment, monitoring, reliability and performance
• Shape platform architecture and longer-term technical direction
• Lead through technical design, code reviews and mentorship while remaining an individual contributor

What We're Looking For

• 12+ years of professional software engineering experience
• Principal, Staff or equivalent-level experience with deep hands-on backend expertise
• Expert-level Python, including async programming and type-safe development
• Strong PostgreSQL experience across schema design, data modelling and performance optimisation
• Strong AWS and cloud-native engineering experience
• Deep experience with microservices, distributed systems and event-driven architecture
• Production experience building LLM-powered products and agentic systems
• Strong understanding of agent orchestration, RAG, tool/function calling and MCP
• Hands-on experience designing LLM evals and observability
• Current, demonstrable fluency with multiple AI coding agents
• Strong technical judgement and the ability to distinguish good AI-generated code from code that simply looks plausible
• Product mindset and a bias towards prototyping, shipping and iterating quickly
• Comfortable providing technical leadership without moving away from hands-on engineering
• Healthcare experience is particularly valuable, particularly around HIPAA, HL7 or FHIR

Tech Stack

Backend: Python 3.12, FastAPI

Data: PostgreSQL, asyncpg, SQLAlchemy

Messaging: Kafka, Procrastinate

Infrastructure: AWS, Docker, Terraform/ECS exposure

Frontend: React, TypeScript

AI: LLMs, coding agents, LangGraph/LangChain, MCP

Evals & Observability: Promptfoo, LangSmith, OpenLLMetry

Why This Role?

• Genuine Principal-level technical influence without giving up coding
• AI is fundamental to both the product and how the engineering team operates
• Build sophisticated agentic systems that are deployed into production
• End-to-end ownership from idea and architecture through deployment and operation
• Direct impact on real healthcare workflows and patient care
• Work with a highly technical team that values speed, engineering judgement and product thinking
• Fully remote across the US

If you're a senior technical leader who still wants to build, already treats AI as a core part of how you engineer software, and wants to help define what AI-native engineering looks like in production, we'd love to speak with you.