The Role
Creates and validates payer claims, benefits, adjudication scenarios, and structured test outputs for agentic AI evaluations. Manually applies benefit and adjudication rules, determines claim outcomes and financial impacts, performs QA, and supports model testing, AI governance, and release readiness. Partners with product, engineering, and governance stakeholders to standardize traceable, repeatable evaluation logic and test data.
Summary Generated by Built In
Requisition Number: 2392029
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:
Required Qualifications:
Preferred Qualifications
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.
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.
Skills Required
- 11+ years of experience in the software industry or a 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 and engineering teams
- Solid payer domain knowledge, including claims, benefits, prior authorization, and policy/editing logic
- Ability to manually apply adjudication and benefit rules to determine accurate claim outcomes
- Experience with structured data formats such as X12 and JSON and with QA processes
- Experience supporting model testing, agent evaluation, or AI governance/review board processes
- Experience building or quality-assuring test data, answer keys, or validation scenarios at scale
- X12 claims experience
- Payer operations file experience
- Familiarity with agentic AI systems or LLM-based automation in a healthcare or payer context
- Working knowledge of Excel-based output generation and data QA tooling
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The Company
What We Do
Optum, part of the UnitedHealth Group family of businesses, 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. At Optum, we support your well-being with an understanding team, extensive benefits and rewarding opportunities. By joining us, you’ll have the resources to drive system transformation while we help you take care of your future. We recognize the power of connection to drive change, improve efficiency and make a difference in health care. Join a team where your skills and ideas can make an impact and where collaboration is key to creating technology that produces healthier outcomes.
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Optum Offices
Hybrid Workspace
Employees engage in a combination of remote and on-site work.
Optum has three workplace models that balance the needs of the business and the responsibilities of each role. These models, core on‑site (5 days/week), hybrid (4 days/week) and telecommute or fully remote, vary by country, role and location.
Typical time on-site:
Not Specified
