TPM (Technical Program Manager)- payer

TPM (Technical Program Manager)

USA Remote

Primary Responsibilities Golden Dataset & Claim Scenario Creation

• Generate test claims as a Payer and Adjudication Subject Matter Expert to support agentic AI solution evaluations, both for internal support functions and governance (Agent Evaluation Systems, AIRB, etc.)
• Generate files to simulate and support Payer Operations AI solutions (benefit, pricing, etc), both for internal support and governance
• Identify or construct representative claim scenarios aligned to business and product requirements, then de-identify and modify data as needed
• Translate product requirements into scalable testing files covering both core functionality and edge cases

Adjudication & Outcome Determination

• Manually apply benefit and adjudication rules to create expected outcomes aligned with the scope and data sources of each agentic solution
• Validation of simulated payer files
• Determine allow/reject determinations with clearly supporting rationale, and calculate financial impacts and member responsibility
• Ensure citation and traceability of determination logic so outcomes can be defended in review

Structured Output Generation & QA

• Create structured outputs - X12, JSON, Excel, and answer keys - to support agent testing and evaluation
• Perform quality assurance on generated files and outcomes to ensure accuracy and consistency

Model Testing, Evaluation & Governance Support

• Provide direct support for model testing, agent evaluation cycles, and AIRB reviews
• Partner with Product, Engineering, and AI Governance stakeholders to ensure datasets meet evaluation and release requirements
• Contribute to standardizing adjudication logic and reasoning so outputs are consistent and repeatable across scenarios

Required Qualifications

• 5+ years of experience in product management, claims operations, or payer testing/QA roles
• Strong payer domain knowledge, including claims, benefits, prior authorization, and policy/editing logic
• Direct experience with operational pain points such as denials, call center burden, and configuration complexity
• Hands-on experience with AI/ML-driven products, including defining use cases and working with data/engineering teams
• Ability to manually apply adjudication and benefit rules to determine accurate claim outcomes
• Comfort working with structured data formats (X12, JSON) and QA processes

Preferred Qualifications

• Experience supporting model testing, agent evaluation, or AI governance/review board processes
• Familiarity with agentic AI systems or LLM-based automation in a healthcare/payer context
• Experience building or QA-ing test data, answer keys, or validation scenarios at scale
• Working knowledge of Excel-based output generation and data QA tooling
• X12 Claims Experience
• Payer Operation file experience