Senior Decision Scientist - Medical Claims and Payment Integrity

Decision Scientist

It's fun to work in a company where people truly BELIEVE in what they are doing!

We're committed to bringing passion and customer focus to the business.

Experience: 6–10 years (techno-functional)

Domain: Medical claims adjudication, edits, payment integrity, denials management

About the Role

Own end-to-end problem solving for claims operations: improve auto-adjudication, reduce rework/denials, and modernize integrations. Partner with business, data, and engineering to deliver measurable gains in first-pass adjudication, throughput, and cost-per-claim.

Key Responsibilities

• Consulting & Value Realization

• Lead discovery workshops and quantify value (autoadjudication %, FPY, rework minutes)

• Define roadmaps, KPIs, operating models, and change plans

• Claims Domain Execution

• Analyze adjudication rules, code edits, COB, pricing, bundling/unbundling, medical policy application

• Design/process 837 (I/P/D) and 835 flows; integrate with payment integrity and audit

• Reduce denial drivers; align reconsideration/appeal handoffs with provider outreach

• Interoperability & Data

• Design EDI X12 interfaces (837/835/276/277) and FHIR-based APIs where relevant

• Define data quality controls, lineage, and auditability

• Automation & AI

• Identify automations (edits tuning, rules orchestration, exception triage)

• Apply GenAI/NLP for denial reasoning extraction and claim note summarization with HITL

• Governance & Delivery

• Backlog management, UAT, benefits tracking, and executive readouts

Must‑Have Qualifications

• Experience: 6–10 years in US healthcare consulting/solution delivery across payers and/or providers.

• Domain Depth: Hands‑on with claims adjudication, Membership/prior auth, care management.

• Compliance: Working knowledge of HIPAA Privacy/Security, PHI/PII handling, audit readiness, data governance.

• Techno‑Functional: Ability to translate business needs into technical designs across cloud, data, APIs, and interoperability.

• GenAI/Analytics: Practical experience with GenAI solutioning (e.g., RAG, prompt engineering, evaluation) and classical analytics (segmentation, anomaly detection).

• Cloud/Data Tools: Exposure to Azure/AWS/GCP, Snowflake/Databricks/BigQuery, SQL/PySpark, ETL/ELT (ADF/Glue), APIs (REST/GraphQL), Kafka.

• Consulting & BA: Proven proposal/RFP experience, SOW/MSA inputs, stakeholder management, requirements elicitation, UAT planning.

• Communication: Executive storytelling, workshop facilitation, and cross‑functional influence.

Preferred Qualifications

• Experience with payment integrity, DRG/APC/fee schedules, pricing engines

• Exposure to cloud data platforms (Azure/AWS/GCP), Snowflake/Databricks, and BI (Power BI/Tableau)

• GenAI/RAG exposure for claims documentation and knowledge retrieval

• Certifications: AHIP, X12/FHIR, HIPAA, Azure/AWS/Databricks

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!

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Experience Level

Senior Level