Founding Engineer

Founding Engineer | AI-Native Healthcare RCM

Shields Group Search is partnering with an AI-native healthcare company to hire its Founding Engineer. This will be the first dedicated engineer on the team, working directly with the CEO to architect, build, and scale the platform powering the business.

The Opportunity

Sequoia recently argued that the world's next trillion-dollar company won't sell software. It will sell outcomes, using AI to deliver services at software-like margins. They call it "Services as Software," and it's flipping the $6T global services market on its head.

Our client is that thesis applied to one of the most broken and most expensive corners of American healthcare: revenue cycle management.

They're building an AI-native RCM platform for complex outpatient specialties. Not another SaaS dashboard that sits on top of legacy workflows. They deliver the actual service: intake, benefits verification, prior authorization, claims, denials, appeals, and patient pay. End to end. AI does the heavy lifting. Humans handle judgment calls.

The company already has paying clients, an existing book of business with ~$50-60M in annual collections, and an offshore operations team. This isn't a pre-revenue startup searching for product-market fit. They're scaling a real business with real revenue and need an engineer who can build the AI layer that turns a services company into a platform company.

Why This Matters

Healthcare RCM is a $150B+ market dominated by legacy vendors running manual processes.

The average practice loses 5-10% of revenue to preventable denials. Prior authorizations alone cost the US healthcare system $35B per year in administrative waste.

For specialty practices such as infusion centers, pain management, and orthopedics, the complexity is even worse:

• Buy-and-bill drug reimbursement
• Step therapy requirements
• Medical vs. pharmacy benefit determination
• Payer-specific formulary rules

Most RCM companies throw headcount at the problem. This company is building AI that replaces headcount with intelligence, compresses margins, and delivers better outcomes at lower cost.

That's the Sequoia thesis in practice: a services company that looks like a tech company from the inside.

What You'll Build

You'll be the first dedicated engineer on the team, working directly with the CEO to architect and ship the platform that powers everything.

The platform, already in development, is a full-stack system built on Next.js, TypeScript, PostgreSQL, and AWS, including ECS Fargate, SQS, RDS, and S3.

Intake and Referral Processing

• Multi-source referral ingestion across fax, email, portal, and EHR
• AI-powered document classification and field extraction via OCR + LLM
• A 3-column review workbench: source document, extracted fields, checklist
• Missing document detection and automated follow-up triggers
• Full state machine from Received through Scheduled

Benefits Verification

• Real-time eligibility checks via payer APIs including Availity, Change Healthcare, and Stedi
• Drug-specific benefit determination across medical vs. pharmacy
• Payer-specific rule engine for coverage requirements and formulary checks

Prior Authorization Automation

• AI-drafted PA submissions with clinical evidence assembly
• Integration with payer portals and FHIR-based electronic PA
• Status tracking, auto-follow-up, and deadline management
• Medical evidence retrieval from PubMed, clinical trials, and FDA drug labels

Claims Intelligence

• Deterministic rules engine for pre-submission claim scrubbing
• Payer-specific edit detection
• Code suggestion based on clinical documentation

Denial Management and Appeals

• Denial categorization and root cause analysis
• AI-generated appeal letters with supporting medical evidence
• Outcome tracking and pattern detection across payers

Command Center

• Real-time dashboards for AR aging, denial rates, and collection trends
• Per-clinic and per-payer analytics
• Staff productivity tracking

This is not a prototype.

This is a production system with live integrations across EHR, payer, fax, and evidence APIs, multi-tenant architecture, and real data flowing through it.

You'll own it, extend it, and scale it.

What We're Looking For

You're a full-stack engineer who's been in the weeds of healthcare.

Ideally, you've worked at a company that touches billing, claims, prior auth, or administrative automation. Companies like:

• Olive AI
• Athelas / Commure
• AKASA
• Candid Health
• Waystar
• Cedar
• Collectly
• Infinitus
• Or similar

You've seen how broken the system is from the inside, and you want to fix it.

Technical Requirements

Strong full-stack skills: TypeScript, React/Next.js, Node.js, PostgreSQL. You'll own the entire stack.

Experience with healthcare data standards: X12 EDI (837/835/270/271), HL7, FHIR. You don't need to know all of them, but you should know what they are and have worked with at least one.

AI/ML integration experience: You've built systems that use LLMs in production. Prompt engineering, RAG pipelines, structured output parsing, model routing. Not research. Production.

Cloud infrastructure: AWS preferred, including ECS, SQS, RDS, S3, and Bedrock. You should be comfortable deploying and operating production services.

Healthcare compliance awareness: HIPAA, BAA requirements, PHI handling. You don't need to be a compliance officer, but you need to build systems that handle protected health information correctly.

Bonus, Not Required but Meaningful

Prior authorization or benefits verification systems. If you've built PA automation, you know how painful and valuable this is.

OCR/document processing pipelines. The platform ingests thousands of faxed referrals and insurance cards.

Payer portal automation: RPA and browser automation. Many payer interactions still require portal navigation.

Multi-tenant SaaS architecture. The platform serves multiple clinics from day one.

Healthcare API integrations: Availity, Change Healthcare, athenahealth, WeInfuse. Direct experience with these systems saves months of ramp-up.

Who You Are

You want to be a founding engineer, not employee #500 at a growth-stage startup.

You want ownership. Real equity, not a rounding error on a cap table.

You've been at your current company long enough. Maybe you're past your cliff. Maybe the company got acquired and the magic is gone. Maybe you're tired of building features that don't matter for a product that doesn't move the needle.

You want to build something that matters.

You care about healthcare. Not because it's trendy, but because you've seen how much waste, how much pain, and how many people get caught in the gears of a system that wasn't designed for them.

You want to fix it with better technology, not more headcount.

You're comfortable with ambiguity. At a founding stage, the roadmap changes. Priorities shift. You'll be making architectural decisions that define the company for years.

That excites you, not scares you.

What We Offer

Founding equity. This is a ground-floor opportunity with meaningful ownership.

Direct access to the CEO. No layers, no politics. You'll work directly with the founder on product, architecture, and strategy.

Revenue from day one. The company isn't burning runway hoping for product-market fit. They have clients. They have collections. They're building AI to scale what's already working.

The Sequoia thesis in practice. You're not joining a SaaS company hoping AI will be a feature. You're joining a services company where AI IS the margin. Every model you ship and every automation you build directly drops to the bottom line.

A massive market. Healthcare RCM is $150B+. Specialty RCM is underserved and growing. The regulatory tailwind, including CMS prior auth reforms and interoperability mandates, is accelerating.

About the Company

Our client is an AI-native revenue cycle management company focused on complex outpatient specialties, including:

• Ambulatory infusion centers
• Pain management
• Orthopedics
• Rheumatology
• And more

The company combines deep operational expertise with AI-powered automation to deliver better financial outcomes for specialty practices.

They're backed by experienced healthcare and technology operators. They move fast, ship weekly, and measure everything.

If you want to build something real at the intersection of AI and healthcare, this is the opportunity.