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)
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure
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