Chief Medical Officer, Payment Integrity

Requirements

• Clinical Leadership & Expertise
• Serve as the senior clinical authority for Payment Integrity solutions, including Claims Editing and Expert Claim Review.
• Guide the enhancement of current products through clinical insight, coding expertise, and interpretation of billing, reimbursement, and operational standards.
• Provide expertise in the application of Medicare, Medicaid, and commercial payer rules, regulations, policies, and procedures.
• Participate in physician peer review activities and support clinical governance processes.
• Partner with Product, Analytics, and Operations teams to translate clinical variation into measurable risk signals and scalable claims logic.
• Evaluate model outputs and workflows for clinical appropriateness, operational feasibility, and provider impact.
• Deliver clinical guidance related to provider appeals and support development and review of appeal responses.
• Communicate complex clinical concepts and rationale clearly to both clinical and non-clinical audiences.
• Support client policy initiatives and adoption of new clinical policies, methodologies, and tools.
• Maintain current knowledge of healthcare delivery trends, reimbursement policy, coding practices, regulatory developments, and technologies impacting payment integrity.
• Strategic Leadership & Market Influence
• Define and advance the clinical strategy for Payment Integrity in alignment with Zelis' business objectives and client priorities.
• Influence product roadmap decisions, including opportunities for automation, clinical review optimization, and policy evolution.
• Balance accuracy, savings, provider experience, operational efficiency, and scalability in strategic decision-making.
• Assess competitive market dynamics, emerging industry trends, and evolving payer/provider challenges.
• Serve as an executive advisor and trusted partner to clients, prospective clients, and internal stakeholders.
• Support Sales and Client teams in executive-level presentations, strategic discussions, and solution positioning.
• Represent Zelis as an industry thought leader through speaking engagements, conferences, published content, and participation in industry forums.
• Contribute to strategic initiatives, partnerships, and acquisition-related diligence activities as needed.
• Lead through influence and collaboration across business units and executive stakeholde

Benefits

Additional Information

At Zelis, we Get Stuff Done. So, let's get to it! A Little About Us Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients. At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview Zelis is seeking a strategic and market-facing Chief Medical Officer (CMO) to help shape the future of payment integrity. This executive leader will bring deep clinical expertise, strong business acumen, and a sophisticated understanding of payer operations, healthcare economics, and emerging technologies. The CMO serves as a trusted clinical authority across the organization and externally with clients, providers, industry partners, and regulators. The role translates complex clinical and coding nuances into scalable payment integrity strategies, informs product and policy direction, and helps ensure solutions are clinically sound, operationally effective, and aligned to evolving market needs. This leader will partner closely with Product, Data Science, Operations, Sales, Client Management, and Executive Leadership to drive innovation, strengthen client confidence, and support Zelis' continued growth as an industry leader in payment accuracy and integrity. The CMO will also represent Zelis externally through industry conferences, executive client engagement, thought leadership, and strategic market activities (expect around 25% travel).

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