Vice President Claims & Payment Integrity Operations

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

Benefits

Additional Information

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. #LI-Onsite 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.

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