Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Vice President of Affordability provides executive leadership for enterprise payment integrity, special investigations, provider payment accuracy, affordability strategy, and cost of care analytics, with oversight of senior leaders across these functions. This role is accountable for setting strategic direction and performance expectations to ensure providers and facilities are paid accurately, consistently, and in full compliance with contract terms, coding standards, reimbursement methodologies, and regulatory requirements, while advancing affordability and reducing avoidable medical expense. The VP leads an integrated, cross-functional approach combining payment accuracy controls, fraud, waste, and abuse prevention, reimbursement validation, and advanced analytics to optimize total cost of care, improve contract performance and accuracy, and drive long-term financial sustainability.

• Define and drive the overarching strategy across payment integrity, provider payment accuracy, special investigations, affordability, and total cost of care, ensuring alignment with financial, compliance, and quality goals
• Oversee end-to-end provider payment accuracy capabilities, including prepay edits, post-pay audits and recovery, reimbursement validation, coding accuracy, payment policy governance, and contract compliance
• Drive enterprise initiatives to reduce medical cost trend through utilization management, unit cost control, site-of-care optimization, and administrative efficiency
• Lead and develop senior leaders over Cost of Care and Special Investigations & Payment Integrity functions, establishing clear priorities, governance, and accountability
• Establish an end-to-end operating model balancing affordability, payment accuracy, compliance, efficiency, and provider experience; define and monitor KPIs, ROI, and savings targets
• Oversee enterprise analytics to identify fee schedule and payment errors, cost drivers, utilization trends, fraud, waste and abuse risks, and provider performance opportunities
• Partner with key stakeholders (e.g., Provider Contracting, Operations, Finance, Medical Management, Product, Technology) to ensure accurate implementation of reimbursement models, contracts, and benefit designs
• Ensure adherence to federal/state regulations, BCBSA requirements, and internal policies, while coordinating fraud, waste and abuse detection, investigation, and resolution efforts
• Oversee vendor selection, performance, and optimization across payment integrity, analytics, audit, and investigation functions

Skills:

• Executive leadership in payment integrity, affordability, provider reimbursement, claims payment accuracy, and cost of care strategy
• Deep expertise in provider payment accuracy capabilities (claims editing, audit/recovery, coding validation, reimbursement logic, contract interpretation, payment policy)
• Strong strategic, analytical, and operational leadership with ability to translate data into enterprise decisions and outcomes
• Exceptional communication and influence skills across executive, matrixed, vendor, and external stakeholders
• Proven ability to lead large, cross-functional teams and balance financial results, provider relationships, compliance, and member impact

Knowledge:

• Comprehensive understanding of reimbursement methodologies (commercial, Medicare, Medicaid), provider contracts, coding/billing practices, rate/fee schedule methodologies and claims systems
• Strong knowledge of affordability drivers, total cost of care management, utilization trends, and value-based care models
• Deep understanding of payment integrity programs (prepay/post-pay), audit strategy, recovery processes, and performance measurement
• Knowledge of fraud, waste, and abuse (FWA) programs, investigative practices, and risk mitigation controls
• Familiarity with healthcare regulatory requirements and industry standards impacting reimbursement and payment accuracy

Experience:

• Minimum 12 years of progressive leadership experience in provider payment/coding billing strategies, payment integrity, affordability, healthcare economics, reimbursement, or related payer/provider functions.
• Demonstrated success leading enterprise payment integrity and affordability initiatives with measurable financial and operational outcomes.
• Experience overseeing advanced analytics, trend forecasting, and provider performance initiatives impacting cost and utilization.
• Proven ability to lead complex vendor ecosystems and cross-functional programs in a matrixed environment.
• Track record of driving large-scale change, operational improvement, and organizational transformation.

Education and Certifications:

• Bachelor’s degree in Business, Health Administration, Finance, or a related field; MBA or MHA is strongly preferred.

Location:

• This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.