SummarySupported by the VP of Cost Containment Analytics, the Vice President, CCR & Data Mining Intelligence and Process Improvement lead the strategy, operating model, analytics enablement, and process improvement agenda for Payment Integrity claim review, data mining, pre-pay, post-payment, and provider education operations. This executive will be responsible for building scalable capabilities that improve claim audit throughput, accuracy, revenue predictability, and speed-to-value across the Payment Integrity business.
The VP will establish repeatable processes for medical claim review concept ideation, develop new audit and review types, advance data mining intelligence, govern centralized rules engine capabilities, and build reporting frameworks that enable leadership to forecast and manage revenue performance. This role will partner closely with audit operations, data engineering, implementation, delivery, product, technology, finance, and client-facing teams to help deliver sustainable double-digit year-over-year growth.
Your role in our mission- Lead the development of a scalable claim review intelligence and data mining strategy across Payment Integrity services, including claim audit, pre-pay, post-payment, and provider education.
- Establish repeatable routines for medical claim review concept ideation, prioritization, testing, deployment, monitoring, and refinement.
- Create and launch new audit and review types that enable organic growth, improve client value, and support new sales opportunities.
- Build intelligent processes to balance audit inventory against operational capacity, improving throughput, accuracy, cycle time, and revenue realization.
- Design and sponsor tools, workflows, and applications that increase the velocity and volume of claim reviews performed by audit operations.
- Establish Provider Education as both a standalone offering and an integrated feature of Payment Integrity delivery.
- Partner with analytics, data engineering, technology, and audit operations teams to deliver and govern a centralized rules engine supporting pre-pay and post-payment workflows.
- Build Weekly Leading Indicator and Monthly Leading Indicator reporting frameworks that improve revenue predictability, operational visibility, and executive decision-making.
- Ensure data engineering and data management processes support scalable growth in reporting, concept development, claim selection, analytics deployment, and delivery.
- Partner with implementation and delivery teams to ensure client onboarding and analytics deployment are defect-free, scalable, and aligned to expected revenue outcomes.
- Lead cross-functional initiatives that improve claim selection precision, audit yield, auditor productivity, operational quality, and client performance.
- Serve as an executive partner to Payment Integrity leadership, translating business growth objectives into actionable analytics, process, reporting, and operational strategies.
What we're looking for- Bachelor's degree in Business, Healthcare Administration, Analytics, Data Science, Information Systems, Finance, or a related field; advanced degree (MBA/MPH) preferred.
- Extensive leadership experience in healthcare claims, Payment Integrity, claim audit, data mining, healthcare analytics, payer operations, or related cost containment functions.
- Demonstrated experience leading enterprise-level analytics, operational transformation, reporting, rules-based workflow, or process improvement initiatives.
- Strong understanding of medical claims data, payment accuracy concepts, claim review workflows, and healthcare payer operations.
- Experience developing audit concepts, claim selection strategies, rules-based processes, operational scorecards, executive reporting, or revenue forecasting frameworks.
- Proven ability to lead cross-functional teams across analytics, operations, technology, implementation, delivery, finance, and business leadership.
- Strong executive presence with the ability to communicate complex analytic and operational concepts clearly to senior leaders, clients, and technical teams.
- Track record of improving operational throughput, quality, scalability, revenue realization, and forecast predictability in a growth-oriented environment.
What you should expect in this role- Fully remote position.
- Opportunity to travel through your work up to 20% of the time.
This posting is intended for pipelining. We will accept applications on an ongoing basis.
The pay range for this position is $240,000.00 - $280,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
