[Remote] Senior Assistant Vice President - Healthcare Claims AI - Technical Product Leader

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.ResponsibilitiesDefine, 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 detectionTranslate 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 prioritizationMaintain a competitive landscape matrix and continuously benchmark against market players (Optum/Change Healthcare, Cotiviti, Cognizant TriZetto, HealthEdge, Conduent, etc.) to inform differentiation strategyPartner 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 applicationDesign 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 teamsChampion explainability-first AI design, ensuring all models produce audit-ready, evidence-grounded outputs suitable for SIU investigations, CMS audits, and payer compliance reviewsApply 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 casesEmbed AI solutions into core claims platforms and systems (QNXT, Facets, Amisys, HealthRules Payer, CSC/DXC, etc.) through platform-agnostic integration and API-first designDesign 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 analysisBuild cross-payer intelligence capabilities that leverage anonymized, aggregated claims data to drive payment accuracy benchmarks, denial pattern optimization, and cost-of-care insightsSupport RFP/RFI responses, orals preparation, and executive presentations for national payer pursuitsDevelop AI-powered provider operations solutions—automated provider issue resolution, correspondence generation, contract interpretation, and fee schedule managementServe 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 payersPartner with account management and business development teams to shape differentiated claims AI solutions for complex, enterprise-level healthcare pursuitsBuild and deliver compelling thought leadership content—white papers, case studies, conference presentations, and analyst briefings—that position EXL as a leader in claims AI innovationRepresent EXL at industry conferences (AHIP, HCCA, SIU conferences, RISE, etc.) through presentations, panel discussions, and live product demonstrationsLead, mentor, and develop a high-performing team of AI engineers, product managers, data scientists, and solution architects focused on claims AIFoster a culture of innovation, collaboration, accountability, and continuous learning within the teamCollaborate with offshore engineering and delivery teams to ensure timely, secure, and scalable implementationBuild and scale an AI Center of Excellence for healthcare claims, establishing reusable agent frameworks, governance playbooks, and best practicesChampion privacy-first design, data anonymization, and compliance with HIPAA, PHI/PII handling, and payer-specific data governance frameworksEnsure all AI solutions meet scalability, security, auditability, and operational excellence requirements for regulated healthcare claims environmentsEstablish governance-grade AI controls including model monitoring, bias detection, drift management, and human-in-the-loop override mechanisms for claims decisioningMaintain compliance with CMS, state DOI regulations, NAIC guidelines, and payer-specific audit requirements for claims processing and payment integritySkills15+ years of progressive experience in AI/ML engineering, technical product management, or platform product leadership roles5+ years of leadership experience in healthcare claims technology, payer claims operations, or health-tech product organizations focused on claims/PIProven track record of building and scaling AI solutions for claims processing, payment integrity, or provider operations—from POC to production at an enterprise scaleExperience with large-scale payer claims engagements ($25M+ in managed services or technology contracts) and familiarity with FTE-to-AI transformation models in claims shopsBachelor's degree in computer science, Engineering, Data Science, or related technical field. Master's degree (M.Tech / MS / MBA) is strongly preferredHands-on and architectural expertise in LLMs, embeddings, vector search, prompt engineering, and RAG pipelinesProficiency with cloud AI platforms: Azure OpenAI, AWS Bedrock (Claude, Sonnet), GCP Vertex AIExperience with agent orchestration frameworks: LangChain, LangGraph, CrewAI, AutoGen, or equivalent Agentic AI frameworksStrong understanding of MCP (Model Context Protocol), A2A protocols, and multi-agent system designFamiliarity with browser/desktop automation tools (Playwright, Selenium) as AI agent execution layers for legacy claims system navigationFamiliarity 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 recoveryStrong knowledge of pre-pay/post-pay review, DRG validation, CPT/ICD-10/HCPCS code editing, COB, subrogation, and FWA detection methodologiesExperience with claims processing platforms and systems (QNXT, Facets, Amisys, HealthRules Payer, CSC/DXC) and provider data managementUnderstanding of healthcare financial models: PMPM, total cost of care, provider reimbursement methodologies (fee-for-service, value-based, capitation), and gainshare/outcome-based pricing structuresFamiliarity with CMS regulations, state DOI requirements, NAIC model acts, and payer audit/compliance frameworks relevant to claims processingExceptional executive communication skills—ability to present AI strategy and business impact to C-suite audiences (CEO, President, COO) at national payer organizationsProven ability to influence cross-functional stakeholders across engineering, delivery, sales, and claims operations teamsExperience leading distributed, global teams (US + offshore) in fast-paced, high-growth environmentsStrong storytelling ability—translating complex AI capabilities into clear business value, ROI narratives, and claims transformation roadmapsExperience building or leading AI Centers of Excellence or reusable agent frameworks specifically for claims processing or payment integrityPatent holder, published researcher, or recognized speaker in the AI/healthcare claims innovation spaceExperience 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 claimsExperience with Databricks, Snowflake, or similar data platforms in healthcare claims analytics contextBackground in consulting or managed services delivery for large payer claims operationsKnowledge of competitive landscape including Optum/Change Healthcare, Cotiviti, Cognizant TriZetto, HealthEdge, Conduent, Gainwell Technologies, and emerging AI-native claims startupsCertified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AHFI), or similar claims/PI certifications a plusCompany OverviewEXL 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 SponsorshipEXL 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.