Senior Vice President, Claims Services and Solutions

Accountabilities:

• • Provide overall executive leadership for the healthcare payer Claims Services organization, establishing strategic direction, operating priorities, performance standards, and long-term growth plans.
  • Build and scale a high-performing, multi-client claims operating model covering the full lifecycle from claim receipt and intake through adjudication, quality review, release, and final disposition.
  • Drive operational excellence across quality, turnaround time, productivity, inventory, pends, backlog, workforce readiness, and client service-level commitments.
  • Lead operational turnaround and stabilization initiatives for complex, underperforming, or high-risk claims environments, restoring performance and client confidence.
  • Establish rigorous quality assurance, audit, root-cause analysis, coaching, release controls, and error-reduction practices.
  • Develop disciplined claims rule governance, operational knowledge management, version-controlled client instructions, and single-source-of-truth practices.
  • Partner with Technology and Product leadership to translate claims requirements into workflow, routing, dashboard, audit, knowledge management, automation, and AI-enabled quality solutions.
  • Lead executive-level client relationships, including quarterly business reviews, governance meetings, steering committees, escalations, renewal discussions, recovery plans, and operational performance reviews.
  • Partner with Sales, Account Management, and Client Services on RFPs, RFIs, discovery sessions, solution design, staffing models, pricing assumptions, statements of work, finalist presentations, renewals, and expansion opportunities.
  • Own financial and operating performance, including budgets, labor utilization, productivity economics, cost of quality, margin improvement, investment decisions, and resource allocation.
  • Develop and maintain a strong claims leadership organization capable of supporting growth, managing complex client requirements, and consistently meeting service commitments.
  • Coach and develop senior leaders while fostering a culture of accountability, continuous improvement, collaboration, operational discipline, and client focus.
  • Identify opportunities to modernize claims administration through technology, automation, analytics, and AI while maintaining appropriate quality, compliance, and operational controls.
  • Use performance data and client feedback to establish improvement priorities and ensure measurable progress across service delivery, quality, efficiency, and customer satisfaction.
  • Contribute to the broader business strategy by identifying market opportunities, strengthening service offerings, and helping shape the future of technology-enabled claims administration.

  Requirements

  • 15+ years of progressive experience in healthcare payer claims, including claims processing, adjudication, complex claims, quality, productivity, service-level management, and operational performance.
  • 10+ years of leadership experience in claims operations, claims services, claims delivery, or claims transformation within a healthcare payer BPO, outsourcing, managed services, BPaaS, payer administrative services, or comparable client-services environment.
  • Demonstrated success improving claims quality, reducing backlog and aging, increasing productivity, stabilizing operations, and rebuilding or strengthening client confidence.
  • Extensive end-to-end knowledge of claims processes, including intake, assignment, workflow management, pends, adjudication, quality assurance, release governance, reporting, escalation, and final disposition.
  • Meaningful experience supporting California healthcare payer markets, including California-based health plans, Medi-Cal programs, managed care organizations, claims administration services, delegated services models, payer administrative services, or comparable California payer environments.
  • Proven executive-level client relationship experience, including QBRs, governance meetings, steering committees, executive escalations, renewal support, recovery conversations, and strategic account management.
  • Experience contributing to business growth through RFPs, RFIs, solution design, staffing models, pricing, statements of work, finalist presentations, renewals, and client expansion opportunities.
  • Strong financial and operational management capabilities, including labor utilization, staffing economics, cost of quality, productivity, margin management, budgeting, and investment tradeoffs.
  • Ability to translate complex claims operating requirements into practical technology, workflow, analytics, automation, and quality-control solutions.
  • Strong understanding of healthcare payer operations, claims administration, service delivery, and the evolving technology landscape supporting these functions.
  • Demonstrated ability to lead large, complex, multi-client operations while balancing service quality, financial performance, workforce requirements, and client expectations.
  • Exceptional executive communication and presentation skills, with the credibility to engage senior leaders and influence decisions across internal and external organizations.
  • Strong strategic thinking combined with hands-on operational discipline and a bias toward measurable results.
  • Proven ability to build, coach, and retain high-performing leadership teams in complex, fast-paced environments.
  • Strong relationship-building, negotiation, problem-solving, decision-making, and change-management skills.
  • Ability to operate effectively in a remote leadership environment while collaborating across geographically distributed teams.

  Benefits

  • Competitive executive-level compensation aligned with the scope and seniority of the position.
  • Fully remote position based in the United States.
  • Opportunity to lead a strategically important healthcare payer services organization during a period of growth and transformation.
  • Significant executive visibility and influence over claims strategy, operating models, technology modernization, client experience, and business growth.
  • Opportunity to work closely with senior leaders across Sales, Client Services, Technology, Product, and Executive Leadership.
  • Ability to shape technology-enabled claims solutions incorporating automation, analytics, workflow modernization, and AI.
  • Opportunity to build and develop a high-performing leadership organization.
  • Direct impact on operational performance, client satisfaction, employee engagement, and long-term business results.
  • Comprehensive employee benefits and programs, subject to applicable plan terms and eligibility.