Vice President, Payment Integrity

E2E Alignment Healthcare USA, LLC; California; Sur place; USD 228 000 - 342 000; Plein temps

Résumé du poste

Alignment Health is seeking a senior leader to architect and drive the Payment Integrity strategy, overseeing a multi-year roadmap, cross-functional governance, and executive reporting. You will lead end-to-end initiatives from clinicians and coding to reimbursement, ensuring compliant, cost-effective outcomes for the payer and providers.

The role requires deep payer experience, proven leadership of large, multi-vendor programs, and a track record of validated savings.

Qualifications

• 12+ years of progressive experience in healthcare Payment Integrity, claims operations, or a closely related function.
• Health plan (payer) experience required, including direct leadership of Payment Integrity programs.
• Experience leading a multi-vendor Payment Integrity portfolio with vendor selection, contract and pricing negotiation, and governance.

Responsabilités

• Develop and lead the multi-year Payment Integrity strategy and capability roadmap with priorities, investments, and performance expectations.
• Own delivery of the approved Payment Integrity financial plan and validated savings commitments; set annual targets and corrective actions.
• Set strategic direction to evolve Payment Integrity from retrospective recovery toward prospective prevention and improved first-pass payment accuracy.
• Establish and govern the enterprise Payment Integrity operating model, policy standards, and control framework.
• Define executive reporting of Payment Integrity savings, financial return, and program performance to drive investment decisions.
• Lead governance for the Payment Integrity vendor portfolio and ensure alignment with enterprise objectives.
• Provide oversight of prepayment and postpayment capabilities, including awareness of compliance, coding, and recovery strategies.

Connaissances

Strategic leadership

Executive collaboration

Formation

Bachelor's degree in business, healthcare administration, finance

Master's degree (preferred)

Outils

Facets

Description du poste

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

Job Duties/Responsibilities:

Payment Integrity Strategy & Program Leadership

Develop, recommend, and lead execution of the multi-year Payment Integrity strategy and capability roadmap, establishing the priorities, investments, operating model, and performance expectations required to advance enterprise medical cost, affordability, and payment accuracy objectives.

Own delivery of the approved Payment Integrity financial plan and validated savings commitments; recommend annual targets, investment requirements, opportunity priorities, and corrective actions in partnership with Finance and Medical Economics.

Set the strategic direction for evolving Payment Integrity from retrospective recovery toward prospective prevention, establishing enterprise priorities that improve first-pass payment accuracy, reduce avoidable medical cost, and minimize administrative burden for Alignment and its providers.

Establish and govern the enterprise Payment Integrity operating model, decision rights, policies, and control framework, including standards for concept approval, savings validation, provider impact, and program performance.

Establish the executive performance framework for Payment Integrity, ensuring transparent measurement of validated net savings, financial return, program effectiveness, quality, provider impact, and operational performance and using those insights to drive investment and portfolio decisions.

Vendor Portfolio & Sourcing Strategy

Set the strategic direction for the Payment Integrity delivery model, determining and recommending the optimal mix of internal capabilities, technology, and external partnerships based on financial return, strategic control, scalability, quality, and provider impact.

Lead the Payment Integrity sourcing and commercial strategy, including evaluation and negotiation of strategic solutions and partnerships, and recommend material vendor selections and contractual commitments in accordance with enterprise financial and approval authorities.

Establish the governance, performance standards, economic expectations, and escalation framework for the Payment Integrity vendor portfolio, holding internal leaders and strategic partners accountable for validated net value, quality, compliance, service performance, and provider impact.

Drive portfolio optimization across internal and external Payment Integrity capabilities, eliminating redundant investment, conflicting concepts, and unnecessary provider abrasion while maximizing enterprise value and strategic alignment.

Prepay & Postpay Program Ownership

Provide executive oversight of the enterprise prepayment integrity portfolio, ensuring clinical, coding, reimbursement, high-dollar, and complex-claim capabilities are prioritized and governed according to financial value, accuracy, scalability, compliance, and provider impact.

Set the strategy, investment priorities, and performance expectations for postpayment audit and recovery capabilities, with accountability for validated financial yield, timeliness, defensibility, and conversion of retrospective findings into sustainable preventive controls.

Provide strategic oversight of Coordination of Benefits and Subrogation capabilities, ensuring these programs are integrated into the broader Payment Integrity portfolio and deliver approved recovery, avoidance, compliance, and member/provider experience outcomes.

Establish executive accountability for Payment Integrity compliance and control effectiveness, ensuring programs operate in accordance with CMS Medicare Advantage payment requirements, provider contractual obligations, applicable prompt-pay requirements, and enterprise policies, with timely escalation of material compliance or regulatory risk.

Analytics, Technology & Innovation

Define the Payment Integrity data, measurement, and analytics strategy, establishing authoritative standards for savings attribution, opportunity prioritization, root-cause insight, financial validation, and executive performance transparency.

Establish executive sponsorship and cross-functional accountability with Technology, Configuration, Data, and Claims Operations to translate Payment Integrity insights into sustainable claims configuration, reimbursement policy, and adjudication improvements that prevent payment errors upstream.

Define strategic Payment Integrity use cases and business requirements for AI, machine learning, automation, and emerging technologies; sponsor pilots and recommend investments that demonstrate measurable value while maintaining appropriate standards for accuracy, explainability, controls, compliance, and provider experience.

Establish and govern a continuous Payment Integrity opportunity portfolio that converts regulatory, coding, billing, provider, market, and industry intelligence into prioritized initiatives supported by clear business cases, investment decisions, and measurable outcomes.

Provider Experience & Cross-Functional Partnership

Establish the enterprise Payment Integrity provider-impact strategy and governance standards, ensuring programs balance financial value with defensible policy, transparency, regulatory requirements, and sustainable provider relationships.

Serve as the senior Payment Integrity partner to Network Management and Contracting, ensuring Payment Integrity strategies and policies align with provider contractual frameworks and leading resolution of material or systemic provider issues requiring executive intervention.

Establish executive-level operating agreements, decision rights, escalation protocols, and closed-loop accountability with the Special Investigations Unit and Provider Disputes and Appeals organizations to ensure effective coordination while maintaining clear functional ownership.

Provide executive leadership across Claims Operations, Finance, Medical Economics, and Compliance to establish authoritative Payment Integrity savings methodologies and ensure financial outcomes are validated, auditable, appropriately attributed, and reflected in enterprise financial reporting.

Team Building & Leadership

Design and scale the Payment Integrity organization, leadership structure, workforce strategy, succession pipeline, and specialized capabilities required to execute the multi-year roadmap and deliver sustainable enterprise outcomes through accountable leaders.

Build a high-performing leadership culture characterized by enterprise accountability, disciplined execution, financial stewardship, innovation, accuracy, and continuous improvement; establish clear performance expectations and hold leaders accountable for business outcomes.

Develop leadership capability and succession depth across the Payment Integrity organization, ensuring the function has the expertise and management capacity required to scale with enterprise growth and strategic priorities.

Governance & Executive Reporting

Provide the Senior Vice President, Claims & Payment Integrity with transparent executive reporting on Payment Integrity financial performance, validated savings, forecast, provider impact, strategic progress, investment requirements, and material risks, and represent the function in executive forums as appropriate or delegated.

Establish management accountability for effective Payment Integrity controls, audit readiness, issue remediation, and sustained regulatory compliance; ensure material control deficiencies, regulatory exposures, and remediation risks are promptly escalated to the Senior Vice President, Claims & Payment Integrity.

Serve as the executive escalation point for material Payment Integrity performance, provider, vendor, financial, and operational issues, escalating matters with broader Claims, enterprise, regulatory, capital, or reputational implications to the Senior Vice President, Claims & Payment Integrity.

Job Requirements:

EXPERIENCE Required:

12+ years of progressive experience in healthcare Payment Integrity, claims operations, or a closely related function, including 7+ years in progressively responsible leadership roles with accountability for complex functions, leaders, financial outcomes, and enterprise initiatives.

Health plan (payer) experience is required, including direct leadership of Payment Integrity programs inside a payer organization.

Demonstrated success setting strategy for and leading a multi-vendor Payment Integrity portfolio, including vendor selection, contract and pricing negotiation, portfolio optimization, financial accountability, and executive-level performance governance.

Deep working knowledge of both prepay and postpay disciplines: clinical and coding edits, DRG validation, itemized bill review, data mining, COB, and subrogation.

Strong command of reimbursement methodology and coding standards, including MS-DRG, APC, fee schedules, NCCI, CPT/HCPCS, and ICD-10.

Track record of delivering measurable, validated savings while actively managing provider abrasion.

Demonstrated executive presence and influence, with experience advising senior executives, translating complex financial and operational issues into enterprise decisions, and building alignment across highly matrixed organizations.

Demonstrated experience establishing strategy, operating models, governance, performance frameworks, and investment priorities for a complex healthcare function.

Proven ability to lead through other leaders and hold cross-functional stakeholders accountable for enterprise outcomes without relying solely on direct reporting authority.

Preferred:

Medicare Advantage experience, including CMS payment policy (NCD/LCD) and MA-specific regulatory requirements.

Payment Integrity vendor-side experience (for example Optum, Cotiviti, Machinify, Zelis, or HealthEdge) in addition to payer experience.

Experience building a Payment Integrity function from a small base, or insourcing previously outsourced programs.

Experience with Facets or a comparable core claims administration platform.

Experience sponsoring, evaluating, and driving value realization from AI/ML-driven Payment Integrity solutions.

Experience leading significant Payment Integrity transformation, operating-model redesign, vendor consolidation, insourcing, or capability modernization initiatives.

EDUCATION Required:

Bachelor's degree in business, healthcare administration, finance, or a related field, or an equivalent combination of education and experience.

Preferred:

Master's degree.

SPECIALIZED SKILLS

Strategic leadership. Enterprise-minded executive capable of translating medical cost, affordability, payment accuracy, and organizational priorities into a multi-year Payment Integrity strategy and making disciplined build, buy, partner, and investment decisions.

Executive decision-making. Demonstrates sound judgment in balancing financial opportunity, operational complexity, regulatory requirements, provider impact, technology investment, and enterprise risk.

Technical and analytical acumen. Fluent in healthcare claims, reimbursement, data, analytics, and Payment Integrity methodologies; able to challenge assumptions, evaluate complex models and vendor methodologies, and translate technical findings into executive decisions. Hands-on coding is not required.

Financial acumen. Strong command of medical cost economics, savings validation, forecasting, ROI, investment prioritization, vendor economics, and financial performance management, with the ability to connect Payment Integrity outcomes to broader enterprise affordability and medical cost objectives.

Strategic vendor leadership. Experienced in developing sourcing strategies, negotiating complex commercial arrangements, evaluating strategic partnerships, and holding vendors accountable for measurable financial, quality, compliance, and provider-experience outcomes.

Enterprise influence. Operates effectively across organizational boundaries, influences senior executives and functional leaders, resolves competing priorities, and builds alignment around complex Payment Integrity, financial, provider, and operational decision.

Organizational leadership. Builds scalable organizations and leadership teams, establishes clear decision rights and accountability, develops succession depth, and creates a culture of disciplined execution and continuous improvement.

Transformation leadership. Leads complex transformation by establishing a clear strategic vision, mobilizing cross-functional stakeholders, prioritizing investments, and ensuring sustainable adoption and measurable business outcomes.

Mission focus. Brings a senior-first mindset to executive decision-making, balancing affordability and payment accuracy objectives with provider relationships, member experience, regulatory obligations, and Alignment Health's broader mission.

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. 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. 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:

$227,952.00 - $341,928.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Equal Opportunity/Affirmative Action Employer

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

Alignment Health is championing a new path in senior care that empowers members to age well and live their most vibrant lives. Our mission-focused team makes high-quality, low-cost care a reality for members every day. Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most. We believe that great work comes from people who are inspired to be their best. We've built a team of people who want to make a difference in the lives of the seniors we serve. Come join the team that is changing health care - one person at a time.