Senior Director, Claims & Payment Integrity Operations

Senior Director, Claims & Payment Integrity Operations Blue Cross of Idaho

• 3.5 Meridian, ID Job Details Full-time $177,000
• $283,200 a year 20 hours ago Benefits Paid holidays Disability insurance Health insurance Dental insurance Tuition reimbursement Paid time off Adoption assistance Employee assistance program Vision insurance 401(k) matching Life insurance Qualifications Affordable Care Act (ACA) Performance dashboard reports Vendor relationship building Succession planning Master's degree in business administration Managerial strategic planning Strategic management Machine learning/AI-based analysis Medical claims processing Medicare Master of Health Administration HIPAA compliance management Operations management Vendor management Managing healthcare operations budgets Master of Public Health Healthcare Administration Healthcare fraud investigations Regulatory compliance in claims processing HIPAA Subrogation State healthcare regulations Bachelor's degree in business administration Change management Certified Professional Coder Team development CMS regulatory compliance Financial operations management Bachelor's degree NCQA standards Quality improvement Centers for Medicare and Medicaid Services (CMS) Vendor relationship management Healthcare team management Master's degree in public health Bachelor's degree in healthcare administration Predictive analytics Healthcare financial management Budget management in healthcare Business Administration Overseeing audit functions Health information management Bachelor's degree in health information management Health Information Management Master's degree in healthcare administration Senior level Regulatory audits AI Cross-functional collaboration Business Master of Business Administration Cross-functional team management 2 years Implementing cost-saving initiatives Data-driven decision making Communication skills Staffing management Cross-functional communication Strategic planning Senior leadership Performance evaluation Full Job Description The Senior Director, Claims & Payment Integrity Operations provides strategic and operational leadership for end-to-end claims processing and payment integrity programs across the health plan enterprise.

This role is accountable for the accuracy, timeliness, and compliance of all claims adjudication functions while driving continuous improvement initiatives that reduce improper payments, recover overpayments, and enhance member and provider experience. The Senior Director serves as a key cross-functional partner to Clinical, Compliance, Finance, Network Management, and Information Technology leadership. This position reports to the Chief Information & Operations Officer and is located at the corporate headquarters in Meridian, Idaho. #LI-Onsite To be considered for this role, you have:

Required Experience:

A minimum of 10 years of progressive experience in health plan claims operations, with at least 5 years in a senior leadership role overseeing large-scale operations and multi-disciplinary teams. Demonstrated expertise in payment integrity programs, including pre-payment clinical editing, post-payment audit recovery, and fraud, waste, and abuse (FWA) detection methodologies. In-depth knowledge of health plan lines of business including commercial, Medicare Advantage, and regulatory environments. Proven track record of driving measurable savings through payment integrity initiatives and operational efficiency programs. Strong familiarity with claims processing platforms (e.g., FACETS, TriZetto) and related adjudication edit engines. Experience managing vendor relationships and third-party administrator (TPA) or delegated entity performance. Demonstrated ability to navigate complex regulatory environments and lead successful responses to CMS and state audits. Exceptional analytical, financial management, and executive communication skills.

Required Education:

Bachelor's Degree in Business Administration, Healthcare Administration, Health Information Management or related field; or equivalent work experience (Two years' relevant experience is equivalent to one-year college); Master's degree (MBA, MHA, MPH) strongly preferred. We'd also love it if you had: Professional certifications such as Certified Professional Coder (CPC), Certified Claims Professional (CCP), Certified Professional Medical Auditor (CPMA), or Accredited Healthcare Fraud Investigator (AHFI). Experience with AI/ML-powered claims review technologies and predictive analytics platforms. Familiarity with value-based care payment models and their intersection with traditional claims adjudication. Prior experience with NCQA accreditation processes and quality improvement initiatives. Experience in a regional or Blues plan environment.

Key Responsibilities:

Claims Operations Leadership Direct all aspects of claims intake, adjudication, and adjudication support functions across commercial, Medicare Advantage, and ASC lines of business. Establish and monitor operational KPIs including claims turnaround time (TAT), auto-adjudication rates, pend rates, and inventory aging, ensuring alignment with regulatory standards (e.g., CMS, state DOI requirements). Lead cross-departmental initiatives to streamline workflows and eliminate unnecessary manual touchpoints, reducing cost per claim while improving quality outcomes. Partner with IT and vendor management teams to optimize claims system configuration, edits, and benefit loading accuracy. Payment Integrity Program Management Design, implement, and continuously improve a comprehensive payment integrity strategy covering pre-payment and post-payment review functions. Oversee clinical and non-clinical editing programs, including logic-based edits, duplicate detection, unbundling, upcoding, and billing anomaly detection. Direct recovery and audit programs including provider audits, third-party liability (TPL) recovery, fraud, waste, and abuse (FWA) detection referrals, and Special Investigations Unit (SIU) coordination. Establish annual savings targets and monitor performance against budget, reporting results to executive leadership and the Board as applicable. Manage relationships with payment integrity vendors, delegated audit entities, and recovery contractors, ensuring contractual performance and ROI accountability. Oversee the management of complex claims categories including coordination of benefits (COB), Medicare secondary payer (MSP), subrogation, and high-dollar claims review. Compliance, Regulatory & Audit Oversight Ensure full compliance with CMS Medicare claims processing requirements, state insurance department regulations, and applicable federal mandates (ACA, ERISA, HIPAA). Serve as the operational lead for internal and external claims-related audits, including CMS program audits, state regulatory audits, and NCQA accreditation reviews. Maintain robust policies and procedures that document claims adjudication standards, integrity controls, and exception handling protocols. Monitor regulatory updates and assess operational impact, leading timely implementation of required changes. People Leadership & Organizational Development Lead, develop, and retain a high-performing team of managers, supervisors, analysts, and examiners, fostering a culture of accountability, continuous learning, and member-centered service. Define workforce planning strategies including staffing models, skill development roadmaps, and succession planning. Champion change management efforts related to system implementations, regulatory changes, and operational restructuring initiatives. Conduct regular performance reviews, set measurable goals aligned with organizational objectives, and address performance gaps proactively. Strategic Planning & Financial Stewardship Develop and manage the annual operating budget for claims and payment integrity functions, including staffing, technology, and vendor expenditures. Contribute to multi-year strategic planning efforts, translating organizational goals into departmental roadmaps with measurable milestones. Present operational and financial performance dashboards to senior and executive leadership on a regular cadence. Identify and evaluate emerging technology solutions, including AI-assisted claims review, predictive analytics, and automation platforms. You will be an excellent fit for this position if you have the following competencies: Strategic Thinking

• Translates broad organizational objectives into actionable operational plans. Collaborative Influence
• Builds strong cross-functional partnerships and earns credibility without formal authority. Change Leadership
• Champions transformation initiatives and guides teams through operational change with clarity. Results Orientation
• Drives accountability through defined metrics, targets, and performance culture. Regulatory Acumen
• Navigates complex compliance and regulatory frameworks with confidence and precision. Analytical Decision-Making
• Leverages data and operational intelligence to make sound, timely business decisions.

As of the date of this posting, a good faith estimate of the current pay range is $177,000 to $283,200. The position is eligible for an annual incentive bonus (variable depending on company and employee performance). The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, travel requirements, internal equity, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer. We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program. We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies. Reasonable accommodations To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.