Technical Product Manager (Risk Adjustment) US Healthcare

We are hiring a Technical Product Manager who can also operate as our Lead Business Analyst . This is a domain-heavy product role: we need someone who genuinely understands US encounter claims data, Medicare, Medicaid, ACA Lines of business, medical chart coding, and audit defence and who can convert that expertise into a product that engineers can build and customers will trust. You will sit between US payer customers, clinical and coding subject matter experts, and an AI/data engineering team. You will own problem definition, requirements, data logic, and acceptance criteria for one or more product lines, and you will be accountable for whether what we ship is correct against CMS and HHS rules — not only whether it was delivered on time. This is a hands‑on role. You will write specifications, interrogate data, define validation logic, and sit in UAT. You will not be managing a team of BAs on day one, though you will set the standard the rest of the organisation follows. What You Will Own Product direction Own the roadmap and backlog for an assigned product area (chart review AI, encounter/EDGE submissions, RAF analytics, or RADV audit readiness). Translate CMS and HHS regulatory change — model version updates, submission deadlines, RADV protocol changes — into product decisions, sequencing, and release planning. Define success measures for each feature (coder throughput, RAF accuracy, submission acceptance rates, audit defensibility) and track outcomes after release. Partner with founders, sales, and implementation on customer discovery, demos, pilots, and beta feedback loops. Requirements and domain logic Elicit, document, and validate business and functional requirements for risk adjustment, HCC analytics, and submission workflows. Write user stories, use cases, process flows, data mapping documents, business rules, and acceptance criteria that an engineer can build from without needing a second conversation. Specify CMS-HCC model logic (including V24 and V28), HHS-HCC logic for ACA, RAF calculation, diagnosis eligibility, and filtering rules in enough detail to be implemented and tested. Define file‑level behaviour for X12 837 I/P/D, TA1, 999, 277CA, MAO‑002, MAO‑004, MMR, MOR, and ACA EDGE Server XML files including enrolment, medical, pharmacy, and supplemental diagnosis submissions. Specify reconciliation logic that traces rejected, dropped, or failed records back to source claims, encounters, charts, and member data. Technical partnership Work directly with data and AI engineers on data models, pipeline behaviour, and edge cases; read and write SQL to validate what the platform actually produces. Define evaluation criteria for AI outputs — code suggestion precision and recall, MEAT evidence quality, hallucination controls, human‑in‑the‑loop review steps, and audit trail requirements. Contribute to API and integration design for EHR, coding platform, and payer data exchange. Own UAT planning and regression scenarios aligned to CMS model files, business rules, and real customer data conditions. What We Are Looking For Required 6–12 years in US healthcare, including at least 3 years in a product management, product owner, or lead BA capacity on a healthcare data or SaaS product. Deep working knowledge of risk adjustment for Medicare Advantage and/or ACA Marketplace : CMS-HCC and/or HHS-HCC models, RAF scoring, HCC mapping, and the diagnosis‑to‑payment relationship. Strong command of healthcare claims data — ICD‑10‑CM, CPT/HCPCS, claim frequency codes, place of service, dates of service, provider and rendering identifiers, and the fields that determine diagnosis eligibility. Practical experience with encounter data submission (RAPS/EDPS) or ACA EDGE server submissions, including response file handling and error resolution. Demonstrated ability to write specifications that engineering teams can build from: business rules, data mappings, state transitions, and acceptance criteria. SQL proficiency sufficient to profile data, reproduce defects, and validate calculations independently. Comfortable in a startup environment — self‑directed, proactive, and able to work with US stakeholders across time zones with strong written and spoken English. Strongly preferred Direct exposure to RADV or HHS‑RADV audits — sampling, medical record retrieval, coder validation, discrepancy handling, or extrapolation methodology. Experience shipping AI or NLP‑enabled products, and defining how model output is measured, reviewed, and governed. Background as a certified coder (CPC, CRC, CCS) or clinical documentation specialist, or close working experience with coding and CDI teams. Prior work at a payer, risk adjustment vendor, or provider‑side risk organisation. Familiarity with HIPAA, PHI handling, and audit trail expectations in production systems. What Success Looks Like First 90 days: fluent in our data model and product lines; owning the backlog for one product area; requirements accepted by engineering with minimal rework. Six months: shipped features that measurably improve coder throughput or submission acceptance rates; owning the CMS/HHS regulatory change pipeline into the product. Twelve months: the reference point internally for risk adjustment logic, and a trusted voice in customer conversations alongside the founders. #J-18808-Ljbffr