Vice President, Payment Integrity

Alignment Health • Orange, CA

1d • $227,952 - $341,928 • Onsite

About The Position

The Vice President, Payment Integrity serves as the senior executive accountable for Alignment Health's enterprise Payment Integrity function and its contribution to payment accuracy, affordability, and medical cost performance. This leader will develop and lead execution of the Payment Integrity strategy, build and scale a high-performing organization, and establish the optimal mix of internal capabilities, technology, and strategic vendor partnerships across prepay and postpay programs.

Alignment's Payment Integrity program currently combines a small internal team with a large vendor footprint. The VP will provide executive leadership over the evolution of the Payment Integrity ecosystem, recommending build, buy, consolidate, insource, and retire decisions and holding internal leaders and external partners accountable for measurable, validated financial and operational outcomes. The VP will also lead the strategic shift from retrospective recovery toward prospective prevention and first-pass payment accuracy while protecting provider relationships, member experience, and regulatory standing.

This role requires payer-side Payment Integrity expertise, a technical and data-driven mindset, strong financial and strategic acumen, and the executive presence to influence and align leaders across Finance, Network, Configuration, Medical Economics, Technology, Claims Operations, and Compliance.

Requirements

• 12+ years of progressive experience in healthcare Payment Integrity, claims operations, or a closely related function, including 7+ years in progressively responsible leadership roles with accountability for complex functions, leaders, financial outcomes, and enterprise initiatives.
• Health plan (payer) experience is required, including direct leadership of Payment Integrity programs inside a payer organization.
• Demonstrated success setting strategy for and leading a multi-vendor Payment Integrity portfolio, including vendor selection, contract and pricing negotiation, portfolio optimization, financial accountability, and executive-level performance governance.
• Deep working knowledge of both prepay and postpay disciplines: clinical and coding edits, DRG validation, itemized bill review, data mining, COB, and subrogation.
• Strong command of reimbursement methodology and coding standards, including MS-DRG, APC, fee schedules, NCCI, CPT/HCPCS, and ICD-10.
• Track record of delivering measurable, validated savings while actively managing provider abrasion.
• Demonstrated executive presence and influence, with experience advising senior executives, translating complex financial and operational issues into enterprise decisions, and building alignment across highly matrixed organizations.
• Demonstrated experience establishing strategy, operating models, governance, performance frameworks, and investment priorities for a complex healthcare function.
• Proven ability to lead through other leaders and hold cross-functional stakeholders accountable for enterprise outcomes without relying solely on direct reporting authority.
• Bachelor's degree in business, healthcare administration, finance, or a related field, or an equivalent combination of education and experience.

Nice To Haves

• Medicare Advantage experience, including CMS payment policy (NCD/LCD) and MA-specific regulatory requirements.
• Payment Integrity vendor-side experience (for example Optum, Cotiviti, Machinify, Zelis, or HealthEdge) in addition to payer experience.
• Experience building a Payment Integrity function from a small base, or insourcing previously outsourced programs.
• Experience with Facets or a comparable core claims administration platform.
• Experience sponsoring, evaluating, and driving value realization from AI/ML-driven Payment Integrity solutions.
• Experience leading significant Payment Integrity transformation, operating-model redesign, vendor consolidation, insourcing, or capability modernization initiatives.
• Master's degree.

Responsibilities

• Develop, recommend, and lead execution of the multi-year Payment Integrity strategy and capability roadmap, establishing the priorities, investments, operating model, and performance expectations required to advance enterprise medical cost, affordability, and payment accuracy objectives.
• Own delivery of the approved Payment Integrity financial plan and validated savings commitments; recommend annual targets, investment requirements, opportunity priorities, and corrective actions in partnership with Finance and Medical Economics.
• Set the strategic direction for evolving Payment Integrity from retrospective recovery toward prospective prevention, establishing enterprise priorities that improve first-pass payment accuracy, reduce avoidable medical cost, and minimize administrative burden for Alignment and its providers.
• Establish and govern the enterprise Payment Integrity operating model, decision rights, policies, and control framework, including standards for concept approval, savings validation, provider impact, and program performance.
• Establish the executive performance framework for Payment Integrity, ensuring transparent measurement of validated net savings, financial return, program effectiveness, quality, provider impact, and operational performance and using those insights to drive investment and portfolio decisions.
• Set the strategic direction for the Payment Integrity delivery model, determining and recommending the optimal mix of internal capabilities, technology, and external partnerships based on financial return, strategic control, scalability, quality, and provider impact.
• Lead the Payment Integrity sourcing and commercial strategy, including evaluation and negotiation of strategic solutions and partnerships, and recommend material vendor selections and contractual commitments in accordance with enterprise financial and approval authorities.
• Establish the governance, performance standards, economic expectations, and escalation framework for the Payment Integrity vendor portfolio, holding internal leaders and strategic partners accountable for validated net value, quality, compliance, service performance, and provider impact.
• Drive portfolio optimization across internal and external Payment Integrity capabilities, eliminating redundant investment, conflicting concepts, and unnecessary provider abrasion while maximizing enterprise value and strategic alignment.
• Provide executive oversight of the enterprise prepayment integrity portfolio, ensuring clinical, coding, reimbursement, high-dollar, and complex-claim capabilities are prioritized and governed according to financial value, accuracy, scalability, compliance, and provider impact.
• Set the strategy, investment priorities, and performance expectations for postpayment audit and recovery capabilities, with accountability for validated financial yield, timeliness, defensibility, and conversion of retrospective findings into sustainable preventive controls.
• Provide strategic oversight of Coordination of Benefits and Subrogation capabilities, ensuring these programs are integrated into the broader Payment Integrity portfolio and deliver approved recovery, avoidance, compliance, and member/provider experience outcomes.
• Establish executive accountability for Payment Integrity compliance and control effectiveness, ensuring programs operate in accordance with CMS Medicare Advantage payment requirements, provider contractual obligations, applicable prompt-pay requirements, and enterprise policies, with timely escalation of material compliance or regulatory risk.
• Define the Payment Integrity data, measurement, and analytics strategy, establishing authoritative standards for savings attribution, opportunity prioritization, root-cause insight, financial validation, and executive performance transparency.
• Establish executive sponsorship and cross-functional accountability with Technology, Configuration, Data, and Claims Operations to translate Payment Integrity insights into sustainable claims configuration, reimbursement policy, and adjudication improvements that prevent payment errors upstream.
• Define strategic Payment Integrity use cases and business requirements for AI, machine learning, automation, and emerging technologies; sponsor pilots and recommend investments that demonstrate measurable value while maintaining appropriate standards for accuracy, explainability, controls, compliance, and provider experience.
• Establish and govern a continuous Payment Integrity opportunity portfolio that converts regulatory, coding, billing, provider, market, and industry intelligence into prioritized initiatives supported by clear business cases, investment decisions, and measurable outcomes.
• Establish the enterprise Payment Integrity provider-impact strategy and governance standards, ensuring programs balance financial value with defensible policy, transparency, regulatory requirements, and sustainable provider relationships.
• Serve as the senior Payment Integrity partner to Network Management and Contracting, ensuring Payment Integrity strategies and policies align with provider contractual frameworks and leading resolution of material or systemic provider issues requiring executive intervention.
• Establish executive-level operating agreements, decision rights, escalation protocols, and closed-loop accountability with the Special Investigations Unit and Provider Disputes and Appeals organizations to ensure effective coordination while maintaining clear functional ownership.
• Provide executive leadership across Claims Operations, Finance, Medical Economics, and Compliance to establish authoritative Payment Integrity savings methodologies and ensure financial outcomes are validated, auditable, appropriately attributed, and reflected in enterprise financial reporting.
• Design and scale the Payment Integrity organization, leadership structure, workforce strategy, succession pipeline, and specialized capabilities required to execute the multi-year roadmap and deliver sustainable enterprise outcomes through accountable leaders.
• Build a high-performing leadership culture characterized by enterprise accountability, disciplined execution, financial stewardship, innovation, accuracy, and continuous improvement; establish clear performance expectations and hold leaders accountable for business outcomes.
• Develop leadership capability and succession depth across the Payment Integrity organization, ensuring the function has the expertise and management capacity required to scale with enterprise growth and strategic priorities.
• Provide the Senior Vice President, Claims & Payment Integrity with transparent executive reporting on Payment Integrity financial performance, validated savings, forecast, provider impact, strategic progress, investment requirements, and material risks, and represent the function in executive forums as appropriate or delegated.
• Establish management accountability for effective Payment Integrity controls, audit readiness, issue remediation, and sustained regulatory compliance; ensure material control deficiencies, regulatory exposures, and remediation risks are promptly escalated to the Senior Vice President, Claims & Payment Integrity.
• Serve as the executive escalation point for material Payment Integrity performance, provider, vendor, financial, and operational issues, escalating matters with broader Claims, enterprise, regulatory, capital, or reputational implications to the Senior Vice President, Claims & Payment Integrity.

Benefits

• Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

What This Job Offers

• Job Type: Full-time
• Career Level: Executive