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 & 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 & 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 & 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 & 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 all applicable Company policies, procedures, and business directives, changes including those relating to work location, team assignments, work schedules, and flexible work arrangements

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
Hands-on experience with AI/ML-driven products, including defining use cases and working with data/engineering teams
Direct experience with operational pain points such as denials, call center burden, and configuration complexity
Solid payer domain knowledge, including claims, benefits, prior authorization, and policy/editing logic
Proven ability to manually apply adjudication and benefit rules to determine accurate claim outcomes
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
Working knowledge of Excel-based output generation and data QA tooling
Familiarity with agentic AI systems or LLM-based automation in a healthcare/payer context

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.