Join Optum, a global leader dedicated to improving health outcomes through innovative technology. We are seeking a Senior Business Analyst Consultant to play a pivotal role in developing and evaluating cutting-edge AI solutions for healthcare. This is an opportunity to contribute directly to advancing health optimization and supporting millions in their journey towards healthier lives. Our inclusive culture fosters collaboration with talented peers, offers comprehensive benefits, and provides ample career development pathways. Come make a tangible impact and help us shape the future of health.

We are committed to fostering a diverse and equitable environment, believing that everyone deserves the opportunity to live their healthiest life. Our mission is to make the health system work better for all, addressing disparities and improving outcomes.

As a Senior Business Analyst Consultant, you will leverage your expertise in claims and adjudication to generate sophisticated test data crucial for evaluating agentic AI solutions. This includes creating simulated payer files for AI solutions in benefits and pricing, identifying and refining claim scenarios, and translating product requirements into scalable testing files.

You will meticulously apply adjudication and benefit rules to determine expected claim outcomes, ensuring clear rationale and traceability. This involves validating simulated payer files and calculating financial impacts. Furthermore, you will generate structured outputs like X12, JSON, and Excel answer keys, performing rigorous quality assurance to guarantee accuracy and consistency. You will also provide essential support for model testing, agent evaluation cycles, and AI governance reviews, collaborating closely with Product, Engineering, and AI Governance stakeholders to ensure datasets meet all release requirements.

To excel in this role, you should possess over 11 years of experience in the software industry or a related field, with at least 5 years focused on product management, claims operations, or payer testing/QA. Hands-on experience with AI/ML-driven products, including defining use cases and collaborating with data/engineering teams, is essential.

We are looking for candidates with direct experience addressing operational challenges such as claim denials, call center burdens, and configuration complexities. A solid understanding of payer domain knowledge, encompassing claims, benefits, prior authorization, and policy/editing logic, is required. You must demonstrate a proven ability to manually apply adjudication and benefit rules for accurate claim outcomes and be comfortable working with structured data formats like X12 and JSON, along with robust QA processes. Experience supporting model testing, agent evaluation, or AI governance is highly preferred.