VP, Payment Integrity at Blue Cross… · Durham

Job Description

To provide strategic direction and centralized leadership to the provider payment integrity and reimbursement policy functions inclusive of prepayment clinical and coding requirements and post payment recoupment, to promote accuracy in claims payment and correct coding to drive savings. Leads strategies for reimbursement policy development, claims editing, post payment analytics and recoupment efforts, provider education, coordination of benefits and development of new innovative programs to drive downstream cost savings for the organization. Has direct or matrixed accountability for SIU integration with or other payment integrity activities. Ensures alignment and compliance with industry standards and accountable for cost of care initiatives and assigned targets to provide affordable care to members.

Blue Cross NC is seeking a strategic and innovative Vice President, Payment Integrity to lead the vision, strategy, and execution of enterprise payment integrity programs that advance affordability, payment accuracy, and operational excellence.

As a key member of the leadership team, this executive will oversee initiatives designed to prevent, identify, and recover inaccurate healthcare payments while enhancing provider experience and supporting sustainable healthcare costs. The Vice President will partner across Finance, Medical Economics, Provider Network Management, Clinical Operations, Technology, Compliance, and Legal to drive measurable impact through analytics, automation, and process innovation.

What You'll Do

• Assess the Payment Integrity ecosystem, prioritize high-value opportunities, and establish KPIs for savings, operations, and performance tracking.
• Develop and execute an enterprise-wide Payment Integrity strategy aligned with organizational affordability and performance goals.
• Lead programs focused on payment accuracy, claims integrity, coding validation, recovery operations, coordination of benefits, and related payment integrity functions.
• Leverage advanced analytics, automation, and emerging technologies to identify opportunities, reduce waste, and improve outcomes.
• Establish performance metrics, governance frameworks, and reporting to measure business impact and value realization.
• Partner with provider-facing teams to balance payment accuracy with a positive provider experience.
• Manage a high-performing multi-vendor portfolio by enforcing SLAs, optimizing fee structures, and minimizing provider abrasion.
• Serve as a trusted advisor to executive leadership on payment integrity trends, risks, opportunities, and industry best practices.
• Build and develop a high-performing team while fostering a culture of innovation, accountability, and continuous improvement.

What You'll Bring

• Bachelor's degree in Business, Healthcare Administration, Finance, Public Health, or a related field.
• 12+ years of progressive leadership experience in payment integrity, healthcare economics, claims operations, health plan operations, revenue cycle, or a related healthcare function.
• Proven success leading large-scale strategic initiatives and high-performing teams within a payer, health plan, consulting organization, or healthcare enterprise.
• Deep knowledge of healthcare reimbursement methodologies, claims administration, payment accuracy, and regulatory requirements.
• Strong financial, analytical, and business acumen with the ability to translate complex data into actionable strategies.
• Exceptional executive presence, communication skills, and ability to influence across diverse stakeholder groups.

Why Blue Cross NC

At Blue Cross NC, we're committed to making healthcare better and more affordable for the people we serve. This role offers a unique opportunity to shape the future of payment integrity, influence enterprise strategy, and drive meaningful impact on affordability, operational performance, and healthcare outcomes across North Carolina and beyond.

Join us and help transform healthcare through innovation, integrity, and strategic leadership.

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