Senior Business Analyst Consultant

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Primary Responsibilities:

Golden Dataset and Claim Scenario Creation
Generate test claims as a Payer and Adjudication Subject Matter Expert to support agentic AI solution evaluations, both for internal support functions and governance (Agent Evaluation Systems, AIRB, etc.)
Generate files to simulate and support Payer Operations AI solutions (benefit, pricing, etc), both for internal support and governance
Identify or construct representative claim scenarios aligned to business and product requirements, then de-identify and modify data as needed
Translate product requirements into scalable testing files covering both core functionality and edge cases
Adjudication and Outcome Determination
Manually apply benefit and adjudication rules to create expected outcomes aligned with the scope and data sources of each agentic solution
Validation of simulated payer files
Determine allow/reject determinations with clearly supporting rationale, and calculate financial impacts and member responsibility
Ensure citation and traceability of determination logic so outcomes can be defended in review
Structured Output Generation and QA
Create structured outputs - X12, JSON, Excel, and answer keys - to support agent testing and evaluation
Perform quality assurance on generated files and outcomes to ensure accuracy and consistency
Model Testing, Evaluation and Governance Support
Provide direct support for model testing, agent evaluation cycles, and AIRB reviews
Partner with Product, Engineering, and AI Governance stakeholders to ensure datasets meet evaluation and release requirements
Contribute to standardizing adjudication logic and reasoning so outputs are consistent and repeatable across scenarios
Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

11+ years of experience in software industry or relevant role
5+ years of experience in product management, claims operations, or payer testing/QA roles
Direct experience with operational pain points such as denials, call center burden, and configuration complexity
Hands-on experience with AI/ML-driven products, including defining use cases and working with data/engineering teams
Solid payer domain knowledge, including claims, benefits, prior authorization, and policy/editing logic
Demonstrated ability to manually apply adjudication and benefit rules to determine accurate claim outcomes
Proven comfort working with structured data formats (X12, JSON) and QA processes

Preferred Qualifications

Experience supporting model testing, agent evaluation, or AI governance/review board processes
Experience building or QA-ing test data, answer keys, or validation scenarios at scale
X12 Claims Experience
Payer Operation file experience
Familiarity with agentic AI systems or LLM-based automation in a healthcare/payer context
Working knowledge of Excel-based output generation and data QA tooling

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.