SmartLight Analytics

• Responsible for defining product vision, driving roadmap execution, and ensuring product investments deliver measurable value to customers and the business • Work closely with stakeholders across operations, analytics, engineering, clinical review, and executive leadership to identify opportunities, prioritize initiatives, and translate business needs into product solutions • Own the product lifecycle from discovery through delivery, balancing customer needs, business objectives, and technical considerations to drive successful outcomes • Partner closely with engineering and QA teams throughout the development process while maintaining accountability for product strategy, prioritization, and business impact • Define and communicate product vision, strategy, and roadmap aligned with company objectives • Identify market opportunities, customer pain points, and business needs through stakeholder engagement, research, and data analysis • Prioritize product initiatives based on customer value, business impact, technical feasibility, and strategic alignment • Develop business cases and success metrics for product investments • Maintain and evolve product roadmaps to support organizational priorities and changing market conditions • Collaborate with customers, internal stakeholders, and subject matter experts to understand needs and define product requirements • Translate business objectives into detailed product requirements, user stories, and acceptance criteria • Lead product discovery efforts, including process analysis, workflow design, and feature validation • Partner with engineering and QA teams throughout the development lifecycle

• Analyze itemized hospital bills and claims data to identify billing errors, coding discrepancies, DRG misassignments, and other overpayment opportunities. • Work directly with claims administrators on behalf of ASO clients to secure claim adjustments, recoveries, and repricing. • Perform detailed audits of hospital and facility claims, including itemized bills, UB-04 claim forms, medical records, and remittance advices, to validate billing accuracy. • Analyze DRG assignments and coding to identify DRG upcoding, unbundling, duplicate billing, and other irregularities that affect reimbursement. • Review high-cost and catastrophic claims (typically $100K+) to identify overpayments, contract misapplication, and opportunities for negotiated adjustments. • Evaluate claims against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines to determine appropriate reimbursement. • Understand and apply stop loss (specific and aggregate) provisions, laser terms, and reporting requirements as they relate to claim adjustments and client financial exposure. • Serve as the subject matter expert and advocate on behalf of ASO clients in disputes with claims administrators (TPAs) and carriers regarding claim payment accuracy. • Prepare clear, well-documented findings packages (clinical, contractual, and coding rationale) to support requested claim adjustments and appeals.

Role Description We’re seeking a Machine Learning Data Scientist with deep expertise in healthcare claims data to design, build, and deploy advanced analytics and machine learning modeling solutions. In this role, you’ll transform complex administrative and clinical datasets into actionable insights that improve cost efficiency, care quality, and operational performance across the healthcare ecosystem. You’ll collaborate with data engineers, clinicians, and product teams to develop predictive models, optimize workflows, and support strategic decision‑making. This position is ideal for someone who thrives at the intersection of data science, healthcare operations, and modern machine learning. Key Responsibilities - Machine Learning & Advanced Analytics - Develop, train, and deploy ML models for use cases such as: - Claims cost prediction and utilization forecasting - Fraud, waste, and abuse detection - Risk adjustment and member stratification - Provider performance and network optimization - Apply modern ML techniques including gradient boosting, deep learning, NLP, and probabilistic modeling. - Capable of applying advanced predictive analytics to correlate disparate datasets and events and derive business value. - Build scalable pipelines for feature engineering, model training, validation, and monitoring. - Healthcare Claims Expertise - Analyze and interpret medical, pharmacy, and dental claims (CPT/HCPCS, ICD‑10, DRG, NDC). - Translate domain knowledge into meaningful features and model strategies. - Cross‑Functional Collaboration - Partner with clinicians, product managers, and business stakeholders to define problems and measure outcomes. - Communicate complex analytical findings in clear, actionable terms. Qualifications - Strong proficiency in Python and ML libraries (scikit‑learn, XGBoost, TensorFlow/PyTorch). - Hands-on experience with healthcare claims datasets and coding systems. - Solid understanding of statistical modeling, machine learning algorithms, and data mining techniques. - Strong knowledge and expertise working with SQL. - Ability to translate business needs into analytical solutions. - Must have demonstrated the ability to solve complex problems with minimal direction. Preferred Qualifications - Experience with NLP applied to clinical notes or unstructured healthcare data. - Familiarity with actuarial concepts, risk scoring, or value‑based care models. - Familiarity deploying models into production (MLOps, CI/CD). - Background in health economics, epidemiology, or biostatistics. - Prior work with FHIR, HL7, or interoperability standards. Company Description SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind, SmartLight combats fraud, waste, and abuse in healthcare through our proprietary data analysis and model development. Requiring the bare minimum in employer involvement, our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.

• Attend monthly Business Review meetings with clients providing detailed and analytical data insights as it relates to carrier engagement. • Attend monthly Carrier meetings providing referral findings and leading data-driven discussion • Hands-on delivery of the carrier experience vision, standards and service models • Lead initiatives that strengthen trust, transparency, and partnership with carriers • Identify performance gaps and lead cross‑functional improvement plans • Manage escalations and ensure timely resolution of carrier issues • Champion a consistent, high‑quality experience across all carrier and client touchpoints • Serve as an executive liaison for carrier and client relationships focusing on service, performance and partnership • Develop team capabilities in communication, analytics, relationship management, and problem-solving

• Own and drive end‑to‑end solutions across healthcare claims data initiatives, from problem definition through implementation and validation. • Serve as a senior authority on medical, pharmacy, behavioral health, dental, DME, and ancillary claims data. • Design, build, and optimize advanced SQL‑based data models, views, and automation frameworks with a focus on performance, scalability, and maintainability. • Develop and maintain complex claim adjustment sequencing and disposition logic, including support for split claims and multiple, disparate source configurations. • Build utilization metrics tied directly to underlying service‑level data, including inpatient, outpatient, professional, and behavioral health levels of care. • Apply deep expertise in healthcare transactions and standards, including 837, 834, 820, HL7, and CCDA, to ensure data accuracy and analytical integrity. • Proactively identify data gaps, risks, and improvement opportunities and drive them to resolution without waiting for direction. • Partner closely with product, analytics, engineering, and leadership teams to ensure claims data assets support broader business and client goals.

• Attend monthly Business Review meetings with clients providing detailed and analytical data insights as it relates to carrier engagement • Attend monthly Carrier meetings providing referral findings and leading data-driven discussion • Hands-on delivery of the client medical claims data to external and internal stakeholders • Lead initiatives that strengthen trust, transparency, and partnership with carriers • Identify performance gaps and lead cross‑functional improvement plans • Manage escalations and ensure timely resolution of carrier issues • Champion a consistent, high‑quality experience across all carrier and client touchpoints • Serve as an executive liaison for carrier and client relationships focusing on service, performance and partnership • Develop team capabilities in communication, analytics, relationship management, and problem-solving

• Design, execute, automate, and document tests across engineering products, including web applications, CI/CD pipelines, SSMS & Snowflake databases, Azure Kubernetes Services (AKS), and backend services (APIs, background jobs, etc.). • Build, maintain, and expand automated test suites using Selenium with Python and other modern automation tools. • Write and optimize SQL queries for validating data, troubleshooting issues, and supporting test case execution. • Perform root‑cause analysis to evaluate severity, scope, and validity of reported issues from stakeholders. • Collaborate with engineering teams to define test strategies, acceptance criteria, and regression coverage.

• Design, build, and maintain ETL and reverse-ETL pipelines between Snowflake, Azure Data Factory, and legacy SQL Server systems. • Develop and optimize Snowflake data warehouse models, ensuring performance, reliability, and high availability. • Implement and maintain row-level and column-level security policies to protect sensitive healthcare data. • Partner with the existing SQL Server Data Engineering team to plan and execute the migration of legacy ETL processes and warehouse models to Snowflake and the cloud. • Build and maintain data transformations using dbt. • Monitor pipeline health, troubleshoot failures, and ensure uptime and data integrity across all data flows. • Mentor peers and contribute to engineering best practices, code reviews, and documentation. • Learn and adopt Sigma as the organization’s BI and reporting tool.

• Review medical claims and related medical records to check for billing accuracy and potential savings opportunities. • Assist in identifying issues that may lead to improper payments across professional, facility, and member claims. • Analyze data to identify trends or patterns that may indicate billing or payment concerns. • Use internal and external systems to research claim information and support payment resolution efforts. • Document findings clearly, including identified issues, trends, and recommended next steps. • Support the review of claims associated with possible overpayments based on benefits or policy guidelines. • Communicate findings to internal teams and carrier partners in a clear and professional manner.

• Define and lead SmartLight’s technology strategy, architecture, and roadmap, including build vs. buy decisions, vendor selection, and platform modernization, aligned to company objectives • Own end‑to‑end technology execution across engineering, data, infrastructure, and IT services, ensuring scalable, reliable, secure, and cost‑effective delivery • Establish and enforce best practices for software development, data engineering, cloud infrastructure, DevOps, and quality assurance • Oversee data governance, security, privacy, and compliance programs appropriate for healthcare and regulated data • Lead, develop, and retain high‑performing technical teams, including hiring, performance management, and leadership development • Manage the technology budget, resource planning, and risk management to support business priorities • Partner closely with Product, Operations, and Commercial leaders to translate business priorities into technical outcomes • Serve as a trusted technical advisor to the executive team, providing clear communication, transparency, and decision support