Senior Assistant Vice President - Healthcare Claims AI - Technical Product Leader

AI Product Strategy & Roadmap Ownership 

• 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). 

2. Technical & AI Engineering Leadership 

• 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. 

3. Healthcare Claims Domain & Operational Transformation 

• 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. 

4. Client Engagement & Thought Leadership 

• 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. 

5. Team Leadership & Talent Development 

• 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. 

6. Governance, Compliance & Risk Management 

• 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. 

Experience 

• 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. 

Technical Skills 

• 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). 

Domain Skills 

• 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. 

Leadership & Communication 

• 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. 

Preferred Qualifications 

• 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. 
• 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. 

Leadership & Communication 

• Exceptional executive communication skills—ability to present AI strategy and business impact to C-suite audiences (CEO, President, COO) at national payer organizations.