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
EXL is a provider of Transformation and Outsourcing services to Global 1000 companies in multiple industries It was founded in 1999, and is headquartered in New York, New York, USA, with a workforce of 10001+ employees. Its website is http://www.exlservice.com.Company H1B Sponsorship
EXL has a track record of offering H1B sponsorships, with 1 in 2025, 1 in 2020. Please note that this does not guarantee sponsorship for this specific role.