Vice President, Affordability

Capital Blue Cross•Harrisburg, PA

2h•$170,870 - $321,920•Hybrid

About The Position

The Vice President of Affordability provides executive leadership for enterprise payment integrity, special investigations, provider payment accuracy, affordability strategy, and cost of care analytics, with oversight of senior leaders across these functions. This role is accountable for setting strategic direction and performance expectations to ensure providers and facilities are paid accurately, consistently, and in full compliance with contract terms, coding standards, reimbursement methodologies, and regulatory requirements, while advancing affordability and reducing avoidable medical expense. The VP leads an integrated, cross-functional approach combining payment accuracy controls, fraud, waste, and abuse prevention, reimbursement validation, and advanced analytics to optimize total cost of care, improve contract performance and accuracy, and drive long-term financial sustainability.

Requirements

Executive leadership in payment integrity, affordability, provider reimbursement, claims payment accuracy, and cost of care strategy
Deep expertise in provider payment accuracy capabilities (claims editing, audit/recovery, coding validation, reimbursement logic, contract interpretation, payment policy)
Strong strategic, analytical, and operational leadership with ability to translate data into enterprise decisions and outcomes
Exceptional communication and influence skills across executive, matrixed, vendor, and external stakeholders
Proven ability to lead large, cross-functional teams and balance financial results, provider relationships, compliance, and member impact
Comprehensive understanding of reimbursement methodologies (commercial, Medicare, Medicaid), provider contracts, coding/billing practices, rate/fee schedule methodologies and claims systems
Strong knowledge of affordability drivers, total cost of care management, utilization trends, and value-based care models
Deep understanding of payment integrity programs (prepay/post-pay), audit strategy, recovery processes, and performance measurement
Knowledge of fraud, waste, and abuse (FWA) programs, investigative practices, and risk mitigation controls
Familiarity with healthcare regulatory requirements and industry standards impacting reimbursement and payment accuracy
Minimum 12 years of progressive leadership experience in provider payment/coding billing strategies, payment integrity, affordability, healthcare economics, reimbursement, or related payer/provider functions.
Demonstrated success leading enterprise payment integrity and affordability initiatives with measurable financial and operational outcomes.
Experience overseeing advanced analytics, trend forecasting, and provider performance initiatives impacting cost and utilization.
Proven ability to lead complex vendor ecosystems and cross-functional programs in a matrixed environment.
Track record of driving large-scale change, operational improvement, and organizational transformation.
Bachelor’s degree in Business, Health Administration, Finance, or a related field; MBA or MHA is strongly preferred.

Responsibilities

Define and drive the overarching strategy across payment integrity, provider payment accuracy, special investigations, affordability, and total cost of care, ensuring alignment with financial, compliance, and quality goals
Oversee end-to-end provider payment accuracy capabilities, including prepay edits, post-pay audits and recovery, reimbursement validation, coding accuracy, payment policy governance, and contract compliance
Drive enterprise initiatives to reduce medical cost trend through utilization management, unit cost control, site-of-care optimization, and administrative efficiency
Lead and develop senior leaders over Cost of Care and Special Investigations & Payment Integrity functions, establishing clear priorities, governance, and accountability
Establish an end-to-end operating model balancing affordability, payment accuracy, compliance, efficiency, and provider experience; define and monitor KPIs, ROI, and savings targets
Oversee enterprise analytics to identify fee schedule and payment errors, cost drivers, utilization trends, fraud, waste and abuse risks, and provider performance opportunities
Partner with key stakeholders (e.g., Provider Contracting, Operations, Finance, Medical Management, Product, Technology) to ensure accurate implementation of reimbursement models, contracts, and benefit designs
Ensure adherence to federal/state regulations, BCBSA requirements, and internal policies, while coordinating fraud, waste and abuse detection, investigation, and resolution efforts
Oversee vendor selection, performance, and optimization across payment integrity, analytics, audit, and investigation functions