Vice President, Claims and Provider Operations

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do.Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults.Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity.At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve.About SCANSCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 500,000 members in California, Arizona, Nevada, Oregon, Washington and Texas. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit , , or follow us on LinkedIn; Facebook; and Twitter.The JobThe Vice President, Claims and Provider Operations leads the strategy, performance, and modernization of claims, configuration, provider data, payment integrity, and capitation operations. This role is accountable for building a high-performing, compliant, and scalable operating model that improves accuracy, timeliness, affordability, provider experience, and member outcomes.The Vice President drives operational excellence through strong controls, payment integrity, configuration discipline, AI, automation, analytics, process redesign, and optimization of internal, vendor, and partner-enabled delivery capabilities.You Will 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.Drives affordability through payment integrity, configuration discipline, and disciplined claims controls, including pre-payment and post-payment review, clinical and non-clinical editing, duplicate detection, unbundling, upcoding, billing anomaly detection, provider audits, coordination of benefits, and high-dollar claims review.Owns payment integrity savings targets, vendor and recovery contractor performance, ROI accountability, budget performance, and regular reporting of operational and financial results to senior and executive leadership.Ensures strong regulatory compliance, audit readiness, policy adherence, risk management, and data governance across internal and delegated operations, including CMS Medicare Advantage requirements, provider directory, state regulations and applicable federal mandates.Builds, develops, and retains a high-performing team of directors, managers, supervisors, analysts, examiners, and subject matter experts; creates clear accountability, measurable goals, succession depth, skill development roadmaps, change leadership capability, and a culture of operational excellence and member-centered service.Sets and owns the multi-year claims and payment integrity roadmap, translating operational trends, risks, regulatory changes, emerging technology, and MLR opportunities into actionable strategies, investment recommendations, measurable milestones, and executive performance dashboards.Develops and manages the annual operating budget for claims and payment integrity functions, including staffing, technology, vendor expenditures, partner-enabled delivery capabilities, savings targets, and financial stewardship of operational investments; performs all other duties as assigned.We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.Actively support the achievement of SCAN’s Vision and Goals.Other duties as assigned.Your QualificationsBachelor’s Degree or equivalent experience, MBA Preferred10-15+ years of progressively responsible healthcare operations leadership experience, including senior level accountability for claims operations, payment integrity, provider operations, configuration, provider data, and/or capitation in Medicare Advantage, or related healthcare environment.Demonstrated experience leading large teams, complex transformation initiatives, regulatory operations, operating model redesign, and cross-functional enterprise programs required.Strong knowledge of claims processing, claim editing, system configuration, benefit loading, provider data hierarchy, contract data integrity, prompt-pay requirements, payment accuracy, payment integrity, coordination of benefits, and high-dollar claims review.Demonstrated accountability for provider data management accuracy, including provider hierarchy, demographic, contract, network, and configuration data integrity that supports accurate claims adjudication, payment, provider directory, and compliance outcomes.Exceptional analytical, financial management, and executive communication skills.What's in it for you?Base Pay Range: $260,000-$325,000, Salary + Incentive PlanWork Mode: RemoteAn annual employee bonus programRobust Wellness ProgramGenerous paid-time-off (PTO)11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer daysExcellent 401(k) Retirement Saving Plan with employer matchRobust employee recognition programTuition reimbursementAn opportunity to become part of a team that makes a difference to our members and our community every day!We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.#LI-JK1 #LI-HybridEqual Opportunity Employer/Protected Veterans/Individuals with DisabilitiesThe contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)SummaryLocation: Long Beach Office 3800Type: Full time