Vice President, Claims and Provider Operations
Core
Leads strategy, performance, and modernization of claims, configuration, provider data, payment integrity, and capitation operations for a Medicare Advantage plan.
Role type
Senior VP, Claims and Provider Operations
Builds
Scalable, compliant operating model for claims and provider operations
Domain
Healthcare (Medicare Advantage)
Required skills
Claims operations leadership, payment integrity, provider data management, system configuration, regulatory compliance, financial management, team leadership, operational transformation, analytics, budget management
Preferred skills
MBA, AI/ML expertise
Technologies
AI, automation, predictive analytics, claims systems
Responsibilities
Lead multi-disciplinary organization across claims intake, adjudication, and provider operations; Own end-to-end operational accuracy, timeliness, and compliance; Drive transformation through workflow simplification and automation; Partner with IT, Finance, and Network Management to optimize systems and data; Drive affordability through payment integrity and claims controls; Own payment integrity savings targets and budget performance; Ensure regulatory compliance and audit readiness; Build and retain high-performing teams; Set multi-year roadmap and executive dashboards.
Seniority
Executive (VP), strategy & mentorship