Senior Healthcare Claims Consultant

Job Description:

• Senior Claims Domain Consultant with deep expertise in Healthcare Payer Claims Operations and working knowledge of Generative AI tools such as Claude, Copilot, ChatGPT, or similar LLM-based platforms.
• The consultant will work closely with business, operations, technology, product, and client stakeholders to assess current claims processes, identify improvement opportunities, and define AI-enabled solutions that enhance claims accuracy, reduce manual effort, improve first-pass adjudication, and accelerate operational efficiency.
• The ideal candidate should have strong understanding of medical claims,  prior authorization, claim edits, denials, rework, provider/member data, payment integrity, and regulatory compliance, along with the ability to leverage GenAI tools like Claude for requirements analysis, process documentation, knowledge summarization, workflow optimization, and solution ideation.

Preferred Qualifications

• Experience in claims transformation, claims modernization, or payer platform migration programs.
• Experience with Facets, QNXT, HealthRules, or similar payer platforms.
• Experience in AI-led healthcare transformation projects.
• Exposure to automation tools, analytics platforms, or process mining tools.
• Experience in consulting-led engagements, client workshops, and solution shaping.
• Understanding of payer data models and claims data structures.
• Certification in healthcare domain, business analysis, Agile, or AI/GenAI would be an added advantage.