Vice President, Claims and Provider Operations

About the role

The Vice President, Claims and Provider Operations leads the strategy, performance, and modernization of claims, configuration, provider data, payment integrity, and capitation operations. This role is accountable for building a high-performing, compliant, and scalable operating model that improves accuracy, timeliness, affordability, provider experience, and member outcomes.

Responsibilities

• Leads a multi-disciplinary organization across claims intake, adjudication, configuration, provider data operations, payment integrity, capitation, and operational support, ensuring alignment with enterprise strategy, regulatory requirements, financial performance, provider experience, and member outcomes.
• Owns end-to-end operational accuracy, timeliness, compliance, and control performance across claims and provider operations, with accountability for claims turnaround time, auto-adjudication rate, pend rate, inventory aging, financial accuracy, procedural accuracy, payment accuracy, prompt-pay compliance, and avoidable interest exposure.
• Leads the evolution and transformation of claims and provider operations through workflow simplification, delivery model optimization, elimination of unnecessary manual touchpoints, automation, artificial intelligence, predictive analytics, and continuous improvement practices that improve quality, productivity, scalability, cost per claim, and speed to resolution.
• Partners closely with IT, EDI Operations, Finance, Network Management, Compliance, Clinical, Appeals and Grievances, and other business leaders to optimize claims system configuration, edit logic, benefit loading accuracy, provider and contract data integrity, accumulator logic, dispute root cause remediation, operational readiness, provider experience, and downstream member outcomes for new products, regulations, contracts, and enterprise initiatives.
• Drives affordability through payment integrity, configuration discipline, and disciplined claims controls, including pre-payment and post-payment review, clinical and non-clinical editing, duplicate detection, unbundling, upcoding, billing anomaly detection, provider audits, coordination of benefits, and high-dollar claims review.
• Owns payment integrity savings targets, vendor and recovery contractor performance, ROI accountability, budget performance, and regular reporting of operational and financial results to senior and executive leadership.
• Ensures strong regulatory compliance, audit readiness, policy adherence, risk management, and data governance across internal and delegated operations, including CMS Medicare Advantage requirements, provider directory, state regulations and applicable federal mandates.
• Builds, develops, and retains a high-performing team of directors, managers, supervisors, analysts, examiners, and subject matter experts; creates clear accountability, measurable goals, succession depth, skill development roadmaps, change leadership capability, and a culture of operational excellence and member-centered service.
• Sets and owns the multi-year claims and payment integrity roadmap, translating operational trends, risks, regulatory changes, emerging technology, and MLR opportunities into actionable strategies, investment recommendations, measurable milestones, and executive performance dashboards.
• Develops and manages the annual operating budget for claims and payment integrity functions, including staffing, technology, vendor expenditures, partner-enabled delivery capabilities, savings targets, and financial stewardship of operational investments; performs all other duties as assigned.

Requirements

We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the