Decision Scientist - Healthcare Claims

This Decision Scientist role is a techno-functional position focused on solving complex claims operations challenges for US healthcare payers and providers, covering auto-adjudication, denial management, and payment integrity. You will lead discovery workshops, quantify value through metrics such as first-pass adjudication rates and cost-per-claim, and define roadmaps, KPIs, and operating models. The role involves analyzing adjudication rules, code edits, COB, pricing, and bundling logic, designing 837 and 835 EDI flows, and integrating with payment integrity and audit systems. You will identify automation opportunities including rules orchestration and exception triage, apply GenAI and NLP for denial reasoning extraction and claim note summarization with human-in-the-loop workflows, and design FHIR-based API integrations. Experience with HIPAA compliance, PHI/PII handling, Snowflake, Databricks, BigQuery, and cloud platforms is required.