Associate Vice President, Claim Payment Accuracy

The Associate Vice President, Claim Payment Accuracy owns the enterprise discipline for identifying, prioritizing, and permanently remediating issues that cause claims to pay incorrectly. This is an operational excellence and transformation role, not a day-to-day claims production or quality assurance role. The AVP leads cross-functional work from signal and root cause through corrective action, validation, and sustained control.
The role partners across Payment Integrity, Claim Audit, Claim Operations, Configuration, Technology, Data, Finance, Compliance, Network, and other claim-adjacent functions. Its north star is to reduce avoidable payment leakage and systematically decrease reliance on retrospective Payment Integrity recovery by fixing upstream process, configuration, data, policy, and technology defects.
Fraud, waste, and abuse activities may sit within the organization led by this role; however, the AVP is accountable for the broader claim payment accuracy agenda. Success requires strong analytics, disciplined problem solving, executive influence, and the ability to drive changes across teams without relying solely on direct authority.

Job Duties / Responsibilities
Own the Claim Payment Accuracy Agenda

·   Define and lead the enterprise claim payment accuracy strategy, operating model, governance, and multiyear roadmap.

·   Establish a single, transparent portfolio of known and emerging payment issues across prepay, postpay, audit, operations, configuration, provider, and FWA signals.

·   Create a consistent method to size, prioritize, and sequence issues based on financial exposure, member and provider impact, compliance risk, recurrence, and remediation complexity.

·   Define clear accountability, decision rights, escalation paths, and closure criteria for cross-functional remediation work.

Lead Root-Cause Analytics and Insight

·   Build and direct an analytics-led capability that connects recovery, audit, adjustment, denial, configuration, provider, and operational data to identify systemic payment defects.

·   Translate Payment Integrity recoveries and Claim Audit findings into root-cause themes, quantified exposure, and actionable upstream fixes.

·   Distinguish isolated errors from recurring patterns and enterprise defects, and focus resources on issues with the greatest preventable value.

·   Develop practical measurement for payment accuracy, defect recurrence, time to remediation, prevented loss, and sustained financial impact.

·   Partner with Data and Technology teams to improve data availability, traceability, and analytical tooling. Hands-on coding is not required, but the AVP must be able to challenge methods, interpret results, and direct analysts.

Drive Remediation from Discovery to Sustainability

·   Lead structured root-cause analysis across people, process, policy, configuration, data, vendor, and technology dimensions.

·   Convert findings into funded, owned remediation plans with milestones, dependencies, controls, and measurable outcomes.

·   Coordinate implementation across Claim Operations, Configuration, Product, Technology, Payment Integrity, Claim Audit, Finance, Network, and other impacted functions.

·   Validate that fixes work as intended, quantify prevented value, monitor recurrence, and reopen issues when results are not sustained.

·   Ensure temporary containment is used when necessary while a durable upstream correction is designed and implemented.

Integrate FWA into the Broader Accuracy Model

·   Provide leadership oversight for FWA work housed within the function and ensure appropriate coordination with Compliance, Legal, Payment Integrity, Network, and Claim Operations.

·   Ensure substantiated FWA patterns inform preventive controls, payment policy, provider action, and broader remediation priorities.

·   Maintain clear handoffs for regulatory, investigative, recovery, and operational remediation responsibilities without duplicating Compliance accountability.

Cross-Functional Leadership and Governance

·   Chair or lead governance forums that review the payment accuracy portfolio, remove barriers, assign ownership, and make prioritization decisions.

·   Partner with Payment Integrity to convert retrospective findings into prospective prevention and to prevent duplicate or conflicting interventions.

·   Partner with Claim Audit to translate audit results into enterprise learning and corrective action rather than treating findings as isolated quality events.

·   Partner with Claim Operations to design practical changes that improve accuracy without creating unnecessary operational burden or avoidable disruption.

·   Communicate exposure, decisions, progress, realized and prevented value, and unresolved risk to the SVP, Claims & Payment Integrity and executive leadership.

Build the Capability and Team

·   Design the organization, roles, skills, routines, and analytical capacity required to manage the payment accuracy agenda.

·   Recruit, develop, and lead a team that may include analytics, root-cause, program leadership, and FWA capabilities.

·   Create a culture of fact-based problem solving, ownership, urgency, transparency, and durable resolution.

Job Requirements
Experience

Required

·   10+ years of progressive experience in health plan claims, payment integrity, operational excellence, enterprise transformation, analytics, audit, or a related discipline, including 5+ years leading teams or complex cross-functional programs.

·   Health plan payer experience with a strong understanding of end-to-end claim payment processes and the upstream factors that affect payment accuracy.

·   Demonstrated success identifying systemic problems, conducting or directing root-cause analysis, and driving corrective action across multiple functions.

·   Strong analytical orientation and experience using claims, financial, operational, or audit data to size problems, prioritize work, and validate outcomes.

·   Experience establishing governance, portfolio management, and executive reporting for complex remediation or transformation initiatives.

·   Proven ability to influence senior leaders, resolve competing priorities, and maintain accountability across teams without direct reporting authority.

·   Executive-level communication skills, including the ability to simplify complex issues, quantify impact, recommend decisions, and communicate risk.

Preferred

·   Medicare Advantage and CMS claim payment experience.

·   Experience leading an analytics, payment accuracy, claims transformation, operational excellence, or enterprise remediation function.

·   Working knowledge of healthcare reimbursement, claim configuration, payment policy, provider data, and core claims administration platforms.

·   Experience with Facets or a comparable core claims administration platform.

·   Familiarity with data visualization, SQL, statistical analysis, process improvement, or automation tools; direct technical execution is not required.

Education

·   Required: Bachelor's degree in business, healthcare administration, analytics, finance, information systems, engineering, or a related field, or an equivalent combination of education and experience.

·   Preferred: Master's degree.

Licensure / Certification

·   Required: None.

·   Preferred: Lean, Six Sigma, process improvement, project or program management, analytics, or related certification.

Specialized Skills

·   Systems thinker. Connects downstream payment outcomes to upstream process, policy, configuration, data, technology, and provider causes.

·   Analytical leader. Frames questions, tests assumptions, sizes exposure, evaluates methods, and converts data into decisions.

·   Operational excellence mindset. Builds repeatable mechanisms that eliminate defects at the source rather than managing recurring symptoms.

·   Transformation leadership. Moves complex cross-functional work from diagnosis through implementation, validation, and sustained adoption.

·   Enterprise influence. Creates alignment, clarifies accountability, and drives decisions across organizational boundaries.

·   Financial discipline. Separates identified, recovered, avoided, and validated value and ensures benefits are credible and traceable.

·   Pragmatic judgment. Balances speed, risk, member and provider impact, operational feasibility, and long-term durability.

·   Clear communication. Presents complex claim payment issues in a concise, executive-ready story with a specific decision or action.

Essential Physical Functions:

·   The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

·   1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

·   2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

 

Pay Range: $198,219.00 - $297,329.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.