Hiring: VP Claims & Payment Integrity Operations Company: Blue Cross of Idaho Location: Meridian, ID Job Posted Time: 2026-09-13 10:40:37 Employment Type: Contract Target Skills & Keywords : Change Management, HIPAA, Health Information Management, Medicare, Program Management About the job Experience: •A minimum of 10 years of progressive experience in health plan 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 (fully insured and self-funded/ASO), Individual/Marketplace, Medicare Advantage, and Federal Employee Program (FEP), and the regulatory environments governing each. •Demonstrated success in driving measurable savings and payment accuracy improvements through payment integrity initiatives and operational efficiency programs, with accountability for first-pass yield, financial accuracy, and payment accuracy benchmarks. •Strong working knowledge of claims processing platforms such as TriZetto Facets, and related adjudication and edit engines (e.g., ClaimsXten, Cotiviti, EDIFECS). Required Skills: •Claims Operations Leadership •Direct all aspects of claims intake, adjudication, configuration, and operational support functions across Commercial, Individual/Marketplace, Medicare Advantage, FEP, and self-funded/ASO lines of business. •Establish and monitor operational KPIs including claims turnaround time (TAT), auto-adjudication rate, pend rate, inventory aging, financial accuracy, procedural accuracy, and payment accuracy, ensuring alignment with CMS, state DOI, and BlueCard performance standards. •Lead cross-departmental initiatives to streamline workflows and eliminate unnecessary manual touchpoints, reducing cost per claim while improving quality outcomes. •Partner with IT , EDI operations, and Provider Data Management to optimize claims system configuration, edit logic, benefit loading accuracy, and the integrity of upstream provider and contract data that drive first-pass yield. •Own the operational accountability for prompt-pay compliance and interest payment exposure, partnering with Finance to manage and reduce avoidable interest spend. •Coordinate with the Pharmacy Benefit Manager (PBM) on integrated medical and pharmacy claims processing, accumulator logic, and crossover scenarios. •Partner with Appeals & Grievances on claims-related member and provider disputes, using dispute trends to identify and remediate root-cause defects in adjudication. Qualifications: •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 •Operational familiarity with value-based care payment models and their intersection with traditional claims adjudication. •Prior experience with NCQA accreditation processes and quality improvement initiatives. Interested candidates, please apply directly through the job posting on company's career page or try via AI auto apply on this platform. Don't miss this opportunity to join a forward-thinking team!