Establish Payment Integrity strategy as key member of Cost Stewardship leadership team, partnering with Performance and Affordability teams to optimize healthcare value
Present strategic initiatives and operational results to Board and C-suite stakeholders
Direct pre-pay and post-pay audit programs, recovery operations, and provider-facing activities across all claim types
Manage large-scale service provider relationships and optimize audit performance delivery
Deploy AI/ML solutions and advanced analytics for payment accuracy and competitive advantage
Design enterprise measurement frameworks with KPIs tracking audit effectiveness and recovery performance
Build high-performing teams through strategic talent acquisition, succession planning, and performance management
Lead large-scale organizational change initiatives across matrixed healthcare payer environment

Requirements

Bachelor's degree, MBA or relevant Master’s degree strongly preferred
5-7 years of direct Payment Integrity leadership experience in a healthcare payer environment with responsibility for audit programs, payment validation, and recovery operations
Minimum of 8-10 years of experience in business process design, improvement, and transformation within healthcare payment environments
Minimum of 12-15 years of progressive leadership experience in Healthcare Payment Integrity, Health Plan Claims, Health Plan Operations or related Healthcare management or an equivalent combination of education and experience.
Industry certifications such as CPC, CPMA, CFE, or equivalent strongly preferred
Comprehensive knowledge of medical coding (CPT, ICD-10, HCPCS), billing practices, reimbursement methodologies, and claims adjudication across professional, institutional, and pharmacy claims
Proficiency with SQL, claims processing systems, predictive modeling, and statistical analysis; demonstrated success implementing AI/ML solutions in payment integrity environments
Experience with fraud/waste/abuse detection, COB and subrogation, CMS program integrity requirements, and regulatory compliance
Exceptional executive presence with ability to set enterprise-wide strategic vision and influence across matrixed organizations
Outstanding communication skills across all organizational levels, including Board and C-suite presentations
Proven ability to identify systemic payment inefficiencies, architect comprehensive solutions, and drive consensus among diverse stakeholders
Track record building and developing high-performing leadership teams with specialized expertise.

Benefits

Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
Annual employer contribution to a health savings account.
Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
Award-winning wellness programs that reward you for participation.
Employee Assistance Fund for those in need.
Commute and parking benefits.

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

AI solutionsML solutionsadvanced analyticsSQLpredictive modelingstatistical analysismedical codingbilling practicesreimbursement methodologiesclaims adjudication

Soft Skills

executive presencestrategic visioninfluencecommunication skillsproblem-solvingconsensus buildingteam buildingleadershipperformance managementtalent acquisition

Certifications

CPCCPMACFE