Vice President, Claims and Provider Operations
Core
Leads strategy, performance, and modernization of claims, provider data, payment integrity, and capitation operations for a Medicare Advantage plan.
Role type
Senior executive (Vice President) in healthcare claims and provider operations
Builds
A high-performing, compliant, and scalable operating model for claims and provider operations
Domain
Healthcare (Medicare Advantage) + Claims & Payment Integrity
Required skills
Healthcare operations leadership, claims processing, payment integrity, provider data management, regulatory compliance, team leadership, financial management, strategic planning
Preferred skills
MBA, AI/automation expertise
Technologies
AI, automation, predictive analytics, claims systems
Responsibilities
Lead multi-disciplinary organization across claims intake, adjudication, configuration, and provider data; Drive operational excellence through controls, payment integrity, and process redesign; Partner with IT, Finance, and Compliance to optimize systems and data; Drive affordability through pre/post-payment review and anomaly detection; Own payment integrity savings targets and budget performance; Build and retain high-performing teams; Set multi-year roadmap and translate trends into actionable strategies.
Seniority
Executive (VP), strategy & mentorship
