Vice President Claims & Payment Integrity Operations

Overview The Vice President, Claims & Payment Integrity Operations role is responsible for enterprise‑wide strategy, performance and financial outcomes for all claims administration and payment integrity functions. This role provides strategic and operational leadership for end‑to‑end claims processing and payment integrity programs across the health plan enterprise. The VP is accountable for the accuracy, timeliness, and compliance of all claims adjudication functions while driving continuous improvement initiatives that reduce improper payments, recover overpayments, and enhance member and provider experience. The VP serves as a key cross‑functional partner to Clinical, Compliance, Finance, Network Management, and Information Technology leadership. Location and Reporting This position reports to the Chief Information & Operations Officer and is located at the corporate headquarters in Meridian, Idaho. #LI-Onsite Required Experience A minimum of 10 years of progressive experience in health plan operations, including at least 5 years in a senior leadership role overseeing large‑scale operations and multi‑disciplinary teams. Demonstrated expertise in payment integrity programs, including pre‑payment clinical editing, post‑payment audit recovery, and fraud, waste, and abuse (FWA) detection methodologies. In‑depth knowledge of health plan lines of business including Commercial (fully insured and self‑funded/ASO), Individual/Marketplace, Medicare Advantage, and Federal Employee Program (FEP) and the regulatory environments governing each. Proven track record of driving measurable savings and payment accuracy improvements through payment integrity initiatives and operational efficiency programs, with accountability for first‑pass yield, financial accuracy, and payment accuracy benchmarks. Strong working knowledge of claims processing platforms such as TriZetto Facets and related adjudication and edit engines (e.g., ClaimsXten, Cotiviti, EDIFECS). Experience managing vendor relationships and third‑party administrator (TPA) or delegated entity performance. Demonstrated ability to navigate complex regulatory environments and lead successful responses to CMS and state audits. Exceptional analytical, financial management, and executive communication skills. Required Education Bachelor’s degree in Business Administration, Healthcare Administration, Health Information Management or a related field; or equivalent work experience (two years’ relevant experience equals one‑year college). A Master’s degree (MBA, MHA, MPH) is strongly preferred. Preferred Qualifications Professional certifications such as Certified in Healthcare Compliance (CHC), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Claims Professional (CCP), or Accredited Healthcare Fraud Investigator (AHFI). Executive leadership coursework or fellowship programs (e.g., AHIP Executive Leadership Program). Experience with AI/ML‑powered claims review technologies and predictive analytics platforms. Familiarity with value‑based care payment models and their intersection with traditional claims adjudication. Prior experience with NCQA accreditation processes and quality improvement initiatives. Experience in a Blue Cross Blue Shield Association plan environment, including BlueCard and inter‑plan operational standards. Key Responsibilities Claims Operations Leadership Direct all aspects of claims intake, adjudication, configuration, and operational support functions across Commercial, Individual/Marketplace, Medicare Advantage, FEP, and self‑funded/ASO lines of business. Establish and monitor operational KPIs—including claims turnaround time, auto‑adjudication rate, pending rate, inventory aging, financial accuracy, procedural accuracy, and payment accuracy—to ensure alignment with CMS, state DOI, and BlueCard performance standards. Lead cross‑departmental initiatives to streamline workflows, eliminate unnecessary manual touchpoints, and reduce cost per claim while improving quality outcomes. Partner with IT, EDI operations, and Provider Data Management to optimize claims system configuration, edit logic, and benefit loading accuracy. Payment Integrity Program Management Design, implement, and continuously improve a comprehensive payment integrity strategy covering pre‑payment and post‑payment review functions. Oversee clinical and non‑clinical editing programs, including logic‑based edits, duplicate detection, unbundling, upcoding, and billing anomaly detection. Direct recovery and audit programs—including provider audits, third‑party liability (TPL) recovery, FWA detection referrals, and SIU coordination—and manage relationships with vendors, delegated audit entities, and recovery contractors to ensure contractual performance and ROI. Compliance, Regulatory & Audit Oversight Maintain full compliance with CMS Medicare Advantage claims processing requirements, state insurance department regulations, and applicable federal mandates. Lead internal and external audits, including CMS program audits, state regulatory audits, and NCQA accreditation reviews, while maintaining robust policies and procedures that document claims adjudication standards and exception handling protocols. People Leadership & Organizational Development Lead, develop, and retain a high‑performing team of directors, managers, supervisors, analysts, and examiners. Define workforce planning strategies, succession planning, and champion change management initiatives related to system implementations, regulatory changes, and operational restructuring. Strategic Planning & Financial Stewardship Set and own the enterprise claims and payment integrity strategy, align with corporate growth and value‑based care objectives, and establish a long‑term transformation roadmap. Manage the annual operating budget for claims and payment integrity functions, and present operational and financial performance dashboards to senior leadership on a regular cadence. Competencies Strategic Thinking – translates broad organizational objectives into actionable operational plans. Collaborative Influence – builds strong cross‑functional partnerships and earns credibility without formal authority. Change Leadership – champions transformation initiatives and guides teams through operational change with clarity. Results Orientation – drives accountability through defined metrics, targets, and performance culture. Regulatory Acumen – navigates complex compliance and regulatory frameworks with confidence and precision. Analytical Decision‑Making – leverages data and operational intelligence to make sound, timely business decisions. Reasonable Accommodations To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Blue Cross of Idaho will extend reasonable accommodations to qualified individuals with disabilities who are otherwise not able to fully use electronic and online job application systems. For assistance, please send an email to View email address on click.appcast.io. Equal Opportunity Statement We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, or basis of disability or any other federal, state or local protected class. Blue Cross of Idaho has taken our role as an Idaho-based health insurance company to heart since 1945. As a not‑for‑profit, we are driven to help connect Idahoans to quality and affordable healthcare while building strong networks and services. Equal Opportunity is the Law. EEO is the Law. Supplement. E-Verify. Pay Transparency. #J-18808-Ljbffr Blue Cross of Idaho