Senior Director, Claims & Payment Integrity Operations

Blue Cross of Idaho•Bozeman, MT

2d•Onsite

About The Position

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

Requirements

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.
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.

Nice To Haves

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.

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.