Vice President, Payment Integrity

Alignment Healthcare•Orange, CA

1d•$227,952 - $341,928

About The Position

The Vice President, Payment Integrity is the senior executive accountable for Alignment Health’s enterprise Payment Integrity function and its contribution to payment accuracy, affordability, and medical cost performance. The role develops and leads execution of the Payment Integrity strategy, builds and scales a high-performing organization, and establishes the appropriate mix of internal capabilities, technology, and strategic vendor partnerships across prepay and postpay programs. The VP guides the evolution of the Payment Integrity ecosystem, makes recommendations on building, buying, consolidating, insourcing, or retiring capabilities, and holds internal leaders and external partners accountable for measurable, validated financial and operational outcomes. The role leads a shift from retrospective recovery toward prospective prevention and first-pass payment accuracy while protecting provider relationships, member experience, and regulatory standing. The position requires payer-side Payment Integrity expertise, technical and data-driven judgment, strong financial and strategic acumen, and executive influence across Finance, Network, Configuration, Medical Economics, Technology, Claims Operations, and Compliance. The VP reports Payment Integrity performance, savings, forecasts, provider impact, strategic progress, investments, and material risks to the Senior Vice President, Claims & Payment Integrity, and serves as an executive escalation point for material issues. The role oversees strategy, operating models, governance, performance measurement, vendor sourcing and portfolio management, prepayment and postpayment programs, Coordination of Benefits and Subrogation, analytics and technology innovation, provider-impact practices, compliance, and organizational leadership. It also sponsors the use of AI, machine learning, automation, and other technologies when they demonstrate measurable value and meet appropriate standards for accuracy, explainability, controls, compliance, and provider experience. The position requires a bachelor’s degree in business, healthcare administration, finance, or a related field, or an equivalent combination of education and experience. A master’s degree is preferred. The stated pay range is $227,952.00–$341,928.00; pay may vary based on factors including market location, education, responsibilities, and experience.

Requirements

12 or more years of progressive experience in healthcare Payment Integrity, claims operations, or a closely related function, including 7 or more years in progressively responsible leadership roles.
Health plan (payer) experience, including direct leadership of Payment Integrity programs within 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 prepay and postpay disciplines, including clinical and coding edits, DRG validation, itemized bill review, data mining, Coordination of Benefits, 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.
Executive presence and influence, including experience advising senior executives, translating complex financial and operational issues into enterprise decisions, and building alignment across matrixed organizations.
Experience establishing strategy, operating models, governance, performance frameworks, and investment priorities for a complex healthcare function.
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.
Strategic leadership, including translating medical cost, affordability, payment accuracy, and organizational priorities into a multi-year strategy and making disciplined build, buy, partner, and investment decisions.
Sound executive judgment balancing financial opportunity, operational complexity, regulatory requirements, provider impact, technology investment, and enterprise risk.
Technical and analytical fluency in healthcare claims, reimbursement, data, analytics, and Payment Integrity methodologies; ability to evaluate complex models and vendor methodologies and translate findings into executive decisions. Hands-on coding is not required.
Financial acumen in medical cost economics, savings validation, forecasting, ROI, investment prioritization, vendor economics, and financial performance management.
Strategic vendor leadership, including sourcing strategy, complex commercial negotiations, partnership evaluation, and vendor accountability for financial, quality, compliance, and provider-experience outcomes.
Enterprise influence across organizational boundaries, including resolving competing priorities and aligning leaders around complex Payment Integrity, financial, provider, and operational decisions.
Organizational leadership to build scalable organizations and leadership teams, establish decision rights and accountability, develop succession depth, and foster disciplined execution and continuous improvement.
Transformation leadership to establish a strategic vision, mobilize cross-functional stakeholders, prioritize investments, and ensure sustainable adoption and measurable outcomes.
Mission focus and a senior-first mindset that balances affordability and payment accuracy with provider relationships, member experience, regulatory obligations, and Alignment Health’s mission.
Ability to meet the stated physical demands, with reasonable accommodations available: regularly talk or hear, stand, walk, sit, use hands and fingers, handle or feel objects, tools, or controls, and reach with hands and arms; frequently lift or move up to 10 pounds; close vision and ability to adjust focus.

Nice To Haves

Medicare Advantage experience, including CMS payment policy (NCD/LCD) and MA-specific regulatory requirements.
Payment Integrity vendor-side experience, for example with 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, including priorities, investments, operating model, and performance expectations.
Own delivery of the approved Payment Integrity financial plan and validated savings commitments; recommend annual targets, investments, opportunity priorities, and corrective actions with Finance and Medical Economics.
Shift Payment Integrity from retrospective recovery toward prospective prevention, first-pass payment accuracy, reduced avoidable medical cost, and lower administrative burden.
Establish the enterprise Payment Integrity operating model, decision rights, policies, control framework, and standards for concept approval, savings validation, provider impact, and program performance.
Create an executive performance framework covering validated net savings, financial return, program effectiveness, quality, provider impact, and operational performance; use results to guide investment and portfolio decisions.
Determine and recommend the appropriate mix of internal capabilities, technology, and external partnerships based on financial return, strategic control, scalability, quality, and provider impact.
Lead Payment Integrity sourcing and commercial strategy, including evaluation and negotiation of solutions and partnerships, and recommend material vendor selections and contractual commitments within enterprise approval authorities.
Govern the vendor portfolio through performance standards, economic expectations, and escalation processes; hold internal leaders and partners accountable for validated net value, quality, compliance, service performance, and provider impact.
Optimize internal and external capabilities by eliminating redundant investment, conflicting concepts, and unnecessary provider abrasion while maximizing enterprise value and strategic alignment.
Provide executive oversight of prepayment integrity programs, including clinical, coding, reimbursement, high-dollar, and complex-claim capabilities.
Set strategy, investment priorities, and performance expectations for postpayment audit and recovery, including financial yield, timeliness, defensibility, and conversion of findings into preventive controls.
Oversee Coordination of Benefits and Subrogation as part of the broader Payment Integrity portfolio, with accountability for recovery, avoidance, compliance, and member/provider experience outcomes.
Establish executive accountability for Payment Integrity compliance and control effectiveness in accordance with CMS Medicare Advantage payment requirements, provider contracts, prompt-pay requirements, and enterprise policies; escalate material risks promptly.
Define Payment Integrity data, measurement, and analytics strategy, including standards for savings attribution, opportunity prioritization, root-cause insight, financial validation, and executive transparency.
Sponsor cross-functional work with Technology, Configuration, Data, and Claims Operations to translate Payment Integrity insights into claims configuration, reimbursement policy, and adjudication improvements that prevent errors upstream.
Define strategic use cases and business requirements for AI, machine learning, automation, and emerging technologies; sponsor pilots and recommend investments that demonstrate measurable value and meet appropriate standards.
Govern a continuous opportunity portfolio that converts regulatory, coding, billing, provider, market, and industry intelligence into prioritized initiatives with clear business cases, investment decisions, and measurable outcomes.
Establish provider-impact strategy and governance standards that balance financial value with defensible policy, transparency, regulatory requirements, and sustainable provider relationships.
Partner with Network Management and Contracting to align strategies and policies with provider contractual frameworks and resolve material or systemic provider issues requiring executive intervention.
Establish operating agreements, decision rights, escalation protocols, and closed-loop accountability with the Special Investigations Unit and Provider Disputes and Appeals organizations while maintaining clear functional ownership.
Lead coordination across Claims Operations, Finance, Medical Economics, and Compliance to establish authoritative savings methodologies and ensure financial outcomes are validated, auditable, correctly attributed, and reflected in enterprise reporting.
Design and scale the Payment Integrity organization, leadership structure, workforce strategy, succession pipeline, and specialized capabilities needed to execute the roadmap.
Build a high-performing leadership culture focused on enterprise accountability, disciplined execution, financial stewardship, innovation, accuracy, and continuous improvement; set expectations and hold leaders accountable.
Develop leadership capability and succession depth across the Payment Integrity organization.
Provide transparent executive reporting to the Senior Vice President, Claims & Payment Integrity on financial performance, validated savings, forecasts, provider impact, strategic progress, investments, and material risks; represent the function in executive forums as appropriate or delegated.
Establish management accountability for effective controls, audit readiness, issue remediation, and sustained regulatory compliance; promptly escalate material control deficiencies, regulatory exposures, and remediation risks to the Senior Vice President, Claims & Payment Integrity.
Serve as executive escalation point for material Payment Integrity performance, provider, vendor, financial, and operational issues; escalate matters with broader Claims, enterprise, regulatory, capital, or reputational implications to the Senior Vice President, Claims & Payment Integrity.