Chief Medical Officer, Payment Integrity

Zelis•Atlanta, GA

2d•Hybrid

About The Position

Zelis is seeking a strategic and market-facing Chief Medical Officer (CMO) to help shape the future of payment integrity. This executive leader will bring deep clinical expertise, strong business acumen, and a sophisticated understanding of payer operations, healthcare economics, and emerging technologies. The CMO serves as a trusted clinical authority across the organization and externally with clients, providers, industry partners, and regulators. The role translates complex clinical and coding nuances into scalable payment integrity strategies, informs product and policy direction, and helps ensure solutions are clinically sound, operationally effective, and aligned to evolving market needs. This leader will partner closely with Product, Data Science, Operations, Sales, Client Management, and Executive Leadership to drive innovation, strengthen client confidence, and support Zelis’ continued growth as an industry leader in payment accuracy and integrity. The CMO will also represent Zelis externally through industry conferences, executive client engagement, thought leadership, and strategic market activities (expect around 25% travel).

Requirements

MD or DO degree with current board certification.
Broad clinical experience with strong understanding of healthcare delivery and reimbursement models.
Deep knowledge of commercial payer, Medicare, and Medicaid reimbursement methodologies, policies, and regulations.
Experience within a payer, payment integrity, utilization management, healthcare technology, consulting, or related healthcare services environment.
Demonstrated experience translating clinical expertise into operational, analytical, or technology-enabled solutions.
Executive-level communication and presentation skills, including experience engaging clients, providers, and senior business leaders.
Proven ability to influence cross-functional stakeholders and lead through collaboration in a matrixed environment.

Nice To Haves

Experience in payment integrity, claims editing, coding compliance, or healthcare cost management.
Familiarity with data analytics, AI-enabled workflows, and scalable clinical decision-support methodologies.
Prior experience representing an organization externally through conferences, publications, or industry leadership activities.

Responsibilities

Serve as the senior clinical authority for Payment Integrity solutions, including Claims Editing and Expert Claim Review.
Guide the enhancement of current products through clinical insight, coding expertise, and interpretation of billing, reimbursement, and operational standards.
Provide expertise in the application of Medicare, Medicaid, and commercial payer rules, regulations, policies, and procedures.
Participate in physician peer review activities and support clinical governance processes.
Partner with Product, Analytics, and Operations teams to translate clinical variation into measurable risk signals and scalable claims logic.
Evaluate model outputs and workflows for clinical appropriateness, operational feasibility, and provider impact.
Deliver clinical guidance related to provider appeals and support development and review of appeal responses.
Communicate complex clinical concepts and rationale clearly to both clinical and non-clinical audiences.
Support client policy initiatives and adoption of new clinical policies, methodologies, and tools.
Maintain current knowledge of healthcare delivery trends, reimbursement policy, coding practices, regulatory developments, and technologies impacting payment integrity.
Define and advance the clinical strategy for Payment Integrity in alignment with Zelis’ business objectives and client priorities.
Influence product roadmap decisions, including opportunities for automation, clinical review optimization, and policy evolution.
Balance accuracy, savings, provider experience, operational efficiency, and scalability in strategic decision-making.
Assess competitive market dynamics, emerging industry trends, and evolving payer/provider challenges.
Serve as an executive advisor and trusted partner to clients, prospective clients, and internal stakeholders.
Support Sales and Client teams in executive-level presentations, strategic discussions, and solution positioning.
Represent Zelis as an industry thought leader through speaking engagements, conferences, published content, and participation in industry forums.
Contribute to strategic initiatives, partnerships, and acquisition-related diligence activities as needed.
Lead through influence and collaboration across business units and executive stakeholders.