Overview As Vice President, Claims and Provider Operations, you will lead the strategy and modernization of claims, configuration, provider data, payment integrity, and capitation. You will build a compliant, scalable operating model that improves accuracy, timeliness, provider experience, and member outcomes. You will drive excellence through governance, AI, automation, and analytics while coordinating with IT, Finance, Compliance, and clinical leaders. This role shapes the end-to-end claims ecosystem for Medicare Advantage and related programs at SCAN. You will lead a high-performing team and own the multi-year roadmap and budget for these functions.
Compensation / Benefits- base pay together with incentive plan
- remote work
- annual bonus program
- wellness program
- generous PTO
- 401(k) with employer match
Responsibilities- Lead a multi-disciplinary organization across claims intake, adjudication, configuration, provider data operations, payment integrity, capitation, and operational support aligned with enterprise strategy and regulatory requirements
- Own end-to-end operational accuracy, timeliness, compliance, and control performance for claims and provider operations
- Drive transformation through workflow simplification, automation, AI, analytics, and continuous improvement to improve quality and cost efficiency
- Partner with IT, Finance, Network Management, Compliance, Clinical, Appeals and Grievances to optimize system configuration, data integrity, and downstream outcomes
- Manage payment integrity, including pre/post-payment review, editing, upcoding detection, and high-dollar claims review
- Oversee budgeting, vendor performance, and reporting of operational and financial results to executives
- Ensure regulatory compliance, audit readiness, data governance, and risk management across operations
- Develop and retain a high-performing team with clear accountability and growth plans
- Set and own the multi-year roadmap for claims and payment integrity and translate trends and regulatory changes into action
- Manage annual operating budget for claims and payment integrity, including staffing and technology investments
Key requirements- 10-15+ years of healthcare operations leadership with senior accountability for claims, payment integrity, provider operations, or related areas
- Experience in Medicare Advantage or similar healthcare environment
- Proven ability to lead large teams and execute complex transformation programs
- Strong knowledge of claims processing, editing, system configuration, benefit loading, provider data hierarchy, and prompt-pay requirements
- Accountability for provider data management accuracy supporting claims adjudication and regulatory compliance
- Excellent analytical, financial management, and executive communication skills
- strategic leadership
- executive communication
- cross-functional collaboration
- claims processing and editing
- system configuration and benefit loading
- provider data management
