Insurance Systems SME
Insurance Systems SME
22
Agoura Hills, California, United States
Job Views:
Created Date: 2026-10-02
End Date:
Experience: 10 - 15 years
Salary: 1500
Industry: Others
Openings: 1
Primary Responsibilities :
Product vision and ownership
• Own the platform's product vision, roadmap and backlog; set priorities across all modules and
each monthly release.
• Act as the single point of product authority between the client's leadership and Vistoria's
engineering team.
• Define product success measures (claims turnaround, auto-adjudication rate, loss ratio, fraud
leakage, customer satisfaction) and track them after go-live.
• Make build, configure or defer decisions, and keep the product coherent and reusable for other
insurers and markets.
Business process re-engineering (BPR)
• Map the client's current (as-is) processes end to end onboarding, enrolment, underwriting,
claims submission, adjudication, settlement, fraud, finance and reporting.
• Run gap analysis against international best practice and design target (to-be) processes that
remove manual steps, hand-offs and control weaknesses.
• Guide client leadership through the operating model changes: roles, approval authorities, SLAs,
controls and policies.
• Translate every redesigned process directly into platform workflows, rules and configuration, so
the system enforces the new way of working.
• Lead change management with client teams so the new processes are adopted, not just
installed.
AI and automation
• Identify where AI adds real value: document intelligence for claims and onboarding, auto-
adjudication, clinical and pricing validation, fraud and anomaly scoring, predictive analytics and
conversational service channels.
• Decide what should be manual, rules-based automation or AI, and define the business logic,
data needs and success criteria for each.
• Set guardrails: human sign-off on adverse decisions (denials, fraud flags), explainability, patient
data privacy, and ongoing bias and drift monitoring.
Experience Requirements:
• 10-15 years in insurance, with at least 5 years in medical/health insurance or a TPA (claims,
underwriting or provider network management).
• Detailed knowledge of the systems side of insurance: core policy administration, claims,
underwriting and rating engines, provider portals, eligibility, payments and reinsurance, and
how these components integrate.
• 5+ years as a product owner, product manager or lead business analyst on insurance core
system implementations, with at least two taken from vision through go-live.
• Proven track record leading business process re-engineering or operational transformation at an
insurer or TPA, with measurable results (e.g. faster turnaround, lower cost per claim, reduced
fraud leakage).
• Practical experience applying automation and AI in insurance operations, such as auto-
adjudication, document AI, or fraud and risk scoring.
• Hands-on knowledge of health claims adjudication: benefit structures, pre-authorisation,
provider tariffs, coding of diagnoses and procedures (ICD-10, CPT or equivalent).
• Working knowledge of underwriting and rating, group/corporate schemes, and reinsurance
basics.
• Strong process modelling skills (BPMN or equivalent) and the ability to write specifications,
business rules and acceptance criteria developers can build and QA can test.
• Confident presenting to and advising client executives, and leading workshops with operational
staff.
• Bachelor's degree in insurance, actuarial science, finance, business, health sciences or a related
field.
• Fluent English, written and spoken.
