- Remote, United States
- Remote
- Full-time · Vp
- $260K–$325K per year
- 10–15 years
The Vice President, Claims and Provider Operations leads the strategy, performance, and modernization of claims, configuration, provider data, payment integrity, and capitation operations.
Compensation
Base Pay Range: $260,000-$325,000, Salary + Incentive Plan
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.