Healthcare Claims Executive

Vice President, Healthcare Claims Processing

We are seeking a seasoned healthcare claims executive with deep expertise in claims operations, adjudication, regulatory compliance, and data-driven process optimization. This high-impact leadership role will oversee claims processing across multiple lines of business, ensuring efficiency, accuracy, financial integrity, and strategic growth.

About the Role

As the Vice President of Claims Processing, you will set the strategic vision for claims operations, lead process optimizations, and leverage analytics to drive efficiency and cost-effectiveness. You will be responsible for claims adjudication, payment integrity, provider dispute resolution, regulatory compliance, and stakeholder management. This leader will play a critical role in revenue cycle management (RCM), ensuring that claims processing aligns with payer requirements, contractual obligations, and reimbursement best practices.

Executive Leadership & Strategic Oversight

• Define and execute the long-term strategy for healthcare claims operations, ensuring scalability and efficiency.
• Spearhead policy and procedural enhancements to streamline claims workflows, reduce errors, and optimize turnaround times.
• Partner with IT, finance, and business leaders to implement technology-driven improvements in claims processing systems.
• Ensure compliance with regulatory standards (HIPAA, CMS, payer requirements) and industry best practices.
• Use advanced data analytics and AI-driven insights to identify trends, drive decision-making, and enhance operational performance.

Claims Processing & Payment Integrity

• Oversee the end-to-end claims lifecycle, from intake and adjudication to payment and appeals resolution.
• Establish payment integrity controls to prevent overpayments, fraud, waste, and abuse.
• Lead claims audit initiatives to identify inaccuracies, recover lost revenue, and ensure proper reimbursement.
• Ensure claims are processed accurately and within timely filing limits to avoid denials and revenue losses.
• Monitor and optimize auto-adjudication rates, reducing manual interventions where possible.
• Develop protocols for coordination of benefits (COB), subrogation, and third-party liability (TPL) claims.
• Drive initiatives to reduce claims denials and rework, collaborating with providers and payers on resolution strategies.
• Oversee the grievances and appeals process, ensuring fair and timely resolution of provider and member disputes.

Operational Excellence & Process Innovation

• Develop and implement KPIs, SLAs, and benchmarking metrics to measure claims performance.
• Lead root cause analysis and corrective action plans to address processing inefficiencies and improve claims adjudication accuracy.
• Establish a culture of continuous improvement, leveraging lean methodologies, automation, and AI-driven enhancements.
• Work with IT teams to implement system improvements and ensure claims platforms integrate seamlessly with EHR, billing, and payer systems.
• Optimize claims editing and validation processes, reducing errors and improving first-pass rates.

Client Engagement & Business Growth

• Serve as the primary executive liaison for key clients, ensuring high levels of satisfaction and performance transparency.
• Develop strategic partnerships with healthcare providers, payers, and business stakeholders to optimize claims processing and reimbursement.
• Drive upselling and cross-selling opportunities, expanding service offerings to enhance client value and revenue.
• Lead executive-level business reviews and performance assessments, ensuring alignment with client goals.

Regulatory Compliance & Risk Mitigation

• Ensure strict adherence to federal, state, and payer-specific claims processing regulations, mitigating compliance risks.
• Implement a comprehensive Quality Assurance framework, including audits, performance tracking, and regulatory reporting.
• Lead efforts to stay ahead of industry changes, proactively updating processes to align with new payer policies and government regulations.
• Act as the executive point of contact for escalations related to compliance, disputes, and appeals.
• Ensure all claims processing activities meet Medicare, Medicaid, and commercial payer requirements.

Leadership, Training & Talent Development

• Build and mentor a high-performing claims leadership team, fostering a culture of accountability and professional growth.
• Establish structured career pathing and succession planning for leadership roles within the claims department.
• Oversee training and quality assurance programs, ensuring ongoing development of staff in compliance, analytics, and industry best practices.
• Champion employee engagement and retention initiatives, reducing attrition and enhancing organizational stability.
• Foster a collaborative, performance-driven work environment focused on innovation and continuous improvement.

Performance Management & KPI Tracking

• Develop and implement key performance indicators (KPIs) to measure claims efficiency, accuracy, timeliness, and financial performance.
• Provide executive-level reporting on claims trends, payer behavior, and operational efficiency.
• Collaborate with leadership to set aggressive but achievable performance goals for the claims team.
• Develop and oversee strategies to manage claims inventory, ensuring timely resolution and preventing backlog issues.
• Lead initiatives to reduce administrative costs while improving processing speed and claims accuracy.

Qualifications & Experience

• Progressive leadership experience in healthcare claims processing, revenue cycle management, or payer operations.
• Proven track record of executive-level oversight in a large-scale, multi-state claims environment.
• Deep understanding of healthcare reimbursement models, payer-provider relations, and regulatory compliance.
• Expertise in claims adjudication, appeals, payment integrity, and claims automation technologies.
• Strong financial acumen, with experience in P&L management, cost containment, and operational scaling.
• Exceptional leadership, stakeholder management, and client-facing capabilities.

Why Join Us?

• Lead a mission-critical division within a dynamic and growing organization.
• Shape the future of claims processing through innovation and strategic leadership.
• Competitive executive compensation, performance incentives, and comprehensive benefits.

This is an office-based executive role, requiring a strategic leader who can drive change, optimize operations, and build high-value client relationships.

If you are a visionary claims leader with a passion for innovation and excellence, we invite you to apply.

Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans’ members and providers.

The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plans’ members and providers. The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually. The company has also developed an innovative workflow technology platform, JetStreamTM, to help with traceability, governance, and automation of claims operations for its clients. Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines.

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Flexible schedule
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance
• Hybrid Schedule