[Hiring] Vice President, Claims Integrity & Operations @Professional Health Care Network

Role Description

The Vice President of Claims Integrity & Operations is responsible for the overall strategic direction, operational performance, compliance, financial accuracy, and customer experience of the Claims organization. This executive leader oversees end-to-end claims and encounter operations, ensuring timely and accurate claims adjudication, encounter submission, health plan reporting, financial reconciliation, customer service excellence, audit readiness, and regulatory compliance.

The Vice President serves as the executive owner of claims operational performance and collaborates across Finance, IT, Compliance, Configuration, Provider Relations, and Health Plan partners to deliver accurate payments, regulatory compliance, and exceptional service to members, agencies, and health plan customers.

Qualifications

• Bachelor's degree required.
• 10+ years of progressive leadership experience in healthcare claims operations.
• 5+ years of senior leadership experience managing large-scale claims organizations.
• Demonstrated experience overseeing claims processing, encounter operations, financial reconciliation, customer service, auditing, and regulatory compliance.
• Experience working with Medicare, Medicaid, Commercial, and value-based reimbursement models.
• Proven success leading operational transformation and large-scale process improvement initiatives.

Requirements

• Extensive Knowledge of:
  • Claims adjudication and payment methodologies.
  • Encounter processing and EDI transaction standards.
  • Medicare and Medicaid regulations.
  • CMS compliance requirements.
  • Provider reimbursement methodologies.
  • Financial reconciliation and month-end close processes.
  • Audit and payment integrity programs.
  • Claims system configuration and implementation.
  • Workforce management and operational analytics.
  • Executive communication and stakeholder management.

Benefits

• Equal employment opportunities to all employees and applicants for employment.
• Prohibits discrimination and harassment of any type.
• Will make reasonable accommodations for qualified individuals with known disabilities.

Leadership Responsibilities

• Develop and execute the strategic vision for Claims Operations.
• Lead and mentor operational leaders across claims, encounters, claims servicing, and audit functions.
• Establish organizational goals, key performance indicators, workforce strategies, and succession plans.
• Build high-performing teams focused on operational excellence, accountability, innovation, and continuous improvement.
• Present operational performance, financial results, and strategic recommendations to executive leadership.
• Manage departmental budgets and resource planning.

Proven Personal Attributes

• Ability to multitask in a fast-paced work environment.
• Highly self-motivated and able to work with minimal supervision.
• Customer service oriented with good oral and written communication skills.
• Self-directed, flexible, cooperative, and exhibits the ability to work with minimal supervision.
• Detail oriented and displays good organizational skills.
• Capable of following an issue through to its conclusion.
• Ability to convey a positive and professional image to customers and employees.
• Ability to remain calm under pressure and manage stressful situations.
• Ability to maintain a high level of confidentiality and remain HIPAA compliant.
• Ability to establish highly productive and detailed organizational skills/habits.
• Possess strong, professional written and oral communication skills for in-person, telephonic, and electronic use.