Claims Data Strategy Lead

Job Summary: 

The Claims Data Strategy Lead role is responsible for providing senior‑level, hands‑on leadership across complex healthcare claims data initiatives. This is a highly autonomous individual contributor role with full ownership accountability for identifying problems, driving solutions, and delivering outcomes with minimal oversight. 

The role requires rapid ramp‑up, strong technical judgment, and the ability to translate complex and disparate claims data into scalable, high‑performance analytics that directly support product, client, and business objectives. 

Key Responsibilities: 

• 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, including experience with FACETs, BlueChip, Prime Therapeutics, ESI, and aggregated claims sources. 

• 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. 

• Independently assess unfamiliar data environments and rapidly develop a working understanding of new datasets using systematic, repeatable methodologies. 

• 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. 

• In addition to the responsibilities listed above, this role is expected to operate with the following level of ownership and autonomy: 

• This role carries clear ownership accountability and is expected to proactively drive work forward rather than operate in a task‑by‑task or advisory capacity. 

• Given the seniority and scope of the role, the individual is expected to operate with a high degree of independence, requiring minimal day‑to‑day oversight. 

• Success in this role is defined by the ability to identify problems, propose solutions, and execute through completion. 

Qualifications: 

• Bachelor’s degree in Computer Science, Information Systems, or related field (or equivalent practical experience) 

• 7-10 years of experience working with healthcare data, with deep specialization in claims data and analytics 

• Expert‑level proficiency in SQL and advanced query development across large, complex datasets 

• Extensive experience building and optimizing complex data models, views, and automation frameworks within SQL platforms 

• Strong understanding of healthcare claims data structures, including medical, pharmacy, behavioral health, and ancillary claims 

• Demonstrated ability to develop and maintain complex claim adjustment sequencing and disposition logic 

• Proven ability to independently assess unfamiliar data environments and rapidly develop working solutions 

• Strong analytical, problem‑solving, and critical‑thinking skills 

• Excellent communication and collaboration abilities across technical and non‑technical stakeholders 

• Ability to work independently, take full ownership of initiatives, and manage multiple priorities with minimal oversight 

Preferred Qualifications: 

• Experience working with FACETs, BlueChip, Prime Therapeutics, ESI, or aggregated healthcare claims sources 

• Hands‑on experience with healthcare transactions and standards including 837, 834, 820, HL7, and CCDA 

• Experience developing utilization metrics tied to service‑level claims data (inpatient, outpatient, professional, behavioral health) 

• Strong understanding of performance tuning, query optimization, and scalability considerations in large data environments 

• Experience supporting analytics, product, or client‑facing use cases in healthcare or payment integrity contexts 

• Background in building reusable, table‑driven logic and automation frameworks 

Who is SmartLight Analytics 

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 works for self-funded employers to reduce the wasteful spend in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes. 

Powered by JazzHR