Vice President Claims & Payment Integrity Operations

Vice President, Claims & Payment Integrity Operations

The Vice President, Claims & Payment Integrity Operations role is responsible for enterprise-wide strategy, performance and financial outcomes for all claims administration and payment integrity functions. This role provides strategic and operational leadership for end-to-end claims processing and payment integrity programs across the health plan enterprise. This role is accountable for the accuracy, timeliness, and compliance of all claims adjudication functions while driving continuous improvement initiatives that reduce improper payments, recover overpayments, and enhance member and provider experience. The VP serves as a key cross-functional partner to Clinical, Compliance, Finance, Network Management, and Information Technology leadership.

This position reports to the Chief Information & Operations Officer and is located at the corporate headquarters in Meridian, Idaho.

To be considered for this role, you have:

Required Experience:

• A minimum of 10 years of progressive experience in health plan operations, with at least 5 years in a senior leadership role overseeing large-scale operations and multi-disciplinary teams.
• Demonstrated expertise in payment integrity programs, including pre-payment clinical editing, post-payment audit recovery, and fraud, waste, and abuse (FWA) detection methodologies.
• In-depth knowledge of health plan lines of business including Commercial (fully insured and self-funded/ASO), Individual/Marketplace, Medicare Advantage, and Federal Employee Program (FEP), and the regulatory environments governing each.
• Proven track record of driving measurable savings and payment accuracy improvements through payment integrity initiatives and operational efficiency programs, with accountability for first-pass yield, financial accuracy, and payment accuracy benchmarks.
• Strong working knowledge of claims processing platforms such as TriZetto Facets, and related adjudication and edit engines (e.g., ClaimsXten, Cotiviti, EDIFECS).
• Experience managing vendor relationships and third-party administrator (TPA) or delegated entity performance.
• Demonstrated ability to navigate complex regulatory environments and lead successful responses to CMS and state audits.
• Exceptional analytical, financial management, and executive communication skills.

Required Education: Bachelor's Degree in Business Administration, Healthcare Administration, Health Information Management or related field; or equivalent work experience (Two years' relevant experience is equivalent to one-year college); Master's degree (MBA, MHA, MPH) strongly preferred.

We'd also love it if you had:

• Professional certifications such as Certified in Healthcare Compliance (CHC), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Claims Professional (CCP), or Accredited Healthcare Fraud Investigator (AHFI). Executive leadership coursework or fellowship programs (e.g., AHIP Executive Leadership Program) are also valued.
• Experience with AI/ML-powered claims review technologies and predictive analytics platforms.
• Familiarity with value-based care payment models and their intersection with traditional claims adjudication.
• Prior experience with NCQA accreditation processes and quality improvement initiatives.
• Experience in a Blue Cross Blue Shield Association plan environment, including experience with BlueCard and inter-plan operational standards.

Key Responsibilities:

Claims Operations Leadership

• Direct all aspects of claims intake, adjudication, configuration, and operational support functions across Commercial, Individual/Marketplace, Medicare Advantage, FEP, and self-funded/ASO lines of business.
• Establish and monitor operational KPIs including claims turnaround time (TAT), auto-adjudication rate, pend rate, inventory aging, financial accuracy, procedural accuracy, and payment accuracy, ensuring alignment with CMS, state DOI, and BlueCard performance standards.
• Lead cross-departmental initiatives to streamline workflows and eliminate unnecessary manual touchpoints, reducing cost per claim while improving quality outcomes.
• Partner with IT, EDI operations, and Provider Data Management to optimize claims system configuration, edit logic, benefit loading accuracy, and the integrity of upstream provider and contract data that drive first-pass yield.
• Own the operational accountability for prompt-pay compliance and interest payment exposure, partnering with Finance to manage and reduce avoidable interest spend.
• Coordinate with the Pharmacy Benefit Manager (PBM) on integrated medical and pharmacy claims processing, accumulator logic, and crossover scenarios.
• Partner with Appeals & Grievances on claims-related member and provider disputes, using dispute trends to identify and remediate root-cause defects in adjudication.

Payment Integrity Program Management

• Design, implement, and continuously improve a comprehensive payment integrity strategy covering pre-payment and post-payment review functions.
• Oversee clinical and non-clinical editing programs, including logic-based edits, duplicate detection, unbundling, upcoding, and billing anomaly detection.
• Direct recovery and audit programs including provider audits, third-party liability (TPL) recovery, fraud, waste, and abuse (FWA) detection referrals, and Special Investigations Unit (SIU) coordination.
• Establish annual savings targets and monitor performance against budget, reporting results to executive leadership and the Board as applicable.
• Manage relationships with payment integrity vendors, delegated audit entities, and recovery contractors, ensuring contractual performance and ROI accountability.
• Oversee the management of complex claims categories including coordination of benefits (COB), Medicare secondary payer (MSP), subrogation, and high-dollar claims review.

Compliance, Regulatory & Audit Oversight

• Ensure full compliance with CMS Medicare Advantage claims processing requirements (42 CFR Parts 422 and 423), state insurance department regulations, and applicable federal mandates (ACA, ERISA, HIPAA).
• Serve as the operational lead for internal and external claims-related audits, including CMS program audits, state regulatory audits, and NCQA accreditation reviews.
• Maintain robust policies and procedures that document claims adjudication standards, integrity controls, and exception handling protocols.
• Monitor regulatory updates and assess operational impact, leading timely implementation of required changes.

People Leadership & Organizational Development

• Lead, develop, and retain a high-performing team of directors, managers, supervisors, analysts, and examiners, fostering a culture of accountability, continuous learning, and member-centered service.
• Define workforce planning strategies including staffing models, skill development roadmaps, and succession planning.
• Champion change management efforts related to system implementations, regulatory changes, and operational restructuring initiatives.
• Conduct regular performance reviews, set measurable goals aligned with organizational objectives, and address performance gaps proactively.

Strategic Planning & Financial Stewardship

• Set and own the enterprise claims and payment integrity strategy, aligning with corporate growth, affordability, and value-based care objectives.
• Establish a long-term transformation roadmap to achieve best-in-class cost per claim, first-pass yield, and payment accuracy.
• Define enterprise standards for claims platforms, adjudication models, and payment integrity frameworks.
• Develop and manage the annual operating budget for claims and payment integrity functions, including staffing, technology, and vendor expenditures.
• Contribute to multi-year strategic planning efforts, translating organizational goals into departmental roadmaps with measurable milestones.
• Present operational and financial performance dashboards to senior and executive leadership on a regular cadence.
• Identify and evaluate emerging technology solutions, including AI-assisted claims review, predictive analytics, and automation platforms.

You will be an excellent fit for this position if you have the following competencies:

• Strategic Thinking - Translates broad organizational objectives into actionable operational plans.
• Collaborative Influence - Builds strong cross-functional partnerships and earns credibility without formal authority.
• Change Leadership - Champions transformation initiatives and guides teams through operational change with clarity.
• Results Orientation - Drives accountability through defined metrics, targets, and performance culture.
• Regulatory Acumen - Navigates complex compliance and regulatory frameworks with confidence and precision.
• Analytical Decision-Making - Leverages data and operational intelligence to make sound, timely business decisions.

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex