Vice President, Claims Integrity & Operations

The Vice President of Claims Integrity & Operations is responsible for the overall strategic direction, operational performance, compliance, financial accuracy, and customer experience of the Claims organization. This executive leader oversees end-to-end claims and encounter operations, ensuring timely and accurate claims adjudication, encounter submission, health plan reporting, financial reconciliation, customer service excellence, audit readiness, and regulatory compliance.

The Vice President serves as the executive owner of claims operational performance and collaborates across Finance, IT, Compliance, Configuration, Provider Relations, and Health Plan partners to deliver accurate payments, regulatory compliance, and exceptional service to members, agencies, and health plan customers.

Essential Job Functions and Duties

Claims Processing and Financial Closure

• Provide executive oversight for end-to-end claims operations, including intake, adjudication, adjustments, reprocessing, payment generation, and financial reconciliation.
• Ensure claims are processed accurately, timely, and in accordance with provider contracts, reimbursement methodologies, health plan requirements, and regulatory standards.
• Partner closely with Finance to ensure monthly financial closure activities are completed accurately and on schedule.
• Maintain accountability for claims inventory, turnaround times, auto-adjudication rates, payment accuracy, and productivity metrics.
• Oversee root-cause analysis and remediation of payment errors, configuration issues, system defects, and operational breakdowns.
• Drive automation and system optimization initiatives that improve operational efficiency and reduce administrative costs.

Encounter Operations and Health Plan Customer Management

• Own the organization's encounter strategy and performance,
• Ensure timely, accurate, and compliant submission of encounter data to health plans and regulatory entities.
• Establish controls and monitoring processes to identify and resolve encounter rejections, discrepancies, and data integrity concerns.
• Lead relationships with health plans regarding encounter submissions, reconciliation activities, performance guarantees, corrective action plans, and operational issue resolution.
• Oversee implementation of new health plan encounter requirements, EDI transactions, companion guides, and testing activities.
• Ensure transparency through standardized reporting, scorecards, and executive-level communication with health plan customers.
• Partner with Operations and Technology teams to improve encounter accuracy and acceptance rates.

Claims Customer Service Operations

• Lead all claims-related customer service functions supporting providers, agencies, members, and health plan partners.
• Establish service-level standards and performance metrics for call handling, ticket resolution, first-contact resolution, and customer satisfaction.
• Ensure timely investigation and resolution of escalated claims inquiries and payment disputes.
• Drive continuous improvement of customer experience through streamlined workflows, self-service capabilities, knowledge management, and staff training.
• Partner with Provider Relations and Network teams to improve claims education and reduce avoidable inquiries.
• Create a customer-focused culture emphasizing accountability, responsiveness, accuracy, and professionalism.

Claims Auditing, Compliance, and Payment Integrity

• Oversee claims auditing programs to ensure compliance with contractual, regulatory, and organizational requirements.
• Maintain audit-ready operations for health plan, state, federal, and external regulatory reviews.
• Lead monitoring programs focused on payment accuracy, overpayments, underpayments, encounter compliance, and operational controls.
• Partner with Compliance, Legal, and Internal Audit departments to assess risk and implement corrective actions.
• Ensure adherence to CMS requirements, Medicare Advantage, Medicaid, Commercial, and other applicable regulatory standards.
• Establish and monitor key compliance indicators and corrective action plans.
• Oversee payment integrity initiatives designed to prevent, identify, and recover inappropriate payments.

Leadership Responsibilities

• Develop and execute the strategic vision for Claims Operations.
• Lead and mentor operational leaders across claims, encounters, claims servicing, and audit functions.
• Establish organizational goals, key performance indicators, workforce strategies, and succession plans.
• Build high-performing teams focused on operational excellence, accountability, innovation, and continuous improvement.
• Present operational performance, financial results, and strategic recommendations to executive leadership.
• Manage departmental budgets and resource planning.

Essential Qualifications

• Bachelor's degree required.
• 10 years of progressive leadership experience in healthcare claims operations.
• 5 years of senior leadership experience managing large-scale claims organizations.
• Demonstrated experience overseeing claims processing, encounter operations, financial reconciliation, customer service, auditing, and regulatory compliance.
• Experience working with Medicare, Medicaid, Commercial, and value-based reimbursement models.
• Proven success leading operational transformation and large-scale process improvement initiatives.

Extensive Knowledge of:

• Claims adjudication and payment methodologies.
• Encounter processing and EDI transaction standards.
• Medicare and Medicaid regulations.
• CMS compliance requirements.
• Provider reimbursement methodologies.
• Financial reconciliation and month-end close processes,
• Audit and payment integrity programs.
• Claims system configuration and implementation.
• Workforce management and operational analytics.
• Executive communication and stakeholder management,

Proven Personal Attributes

• Ability to multitask in a fast-paced work environment.
• Highly self-motivated and able to work with minimal supervision,
• Customer service oriented with good oral and written communication skills.
• Self-directed, flexible, cooperative, and exhibits the ability to work with minimal supervision.
• Detail oriented and displays good organizational skills.
• Capable of following an issue through to its conclusion.
• Ability to convey a positive and professional image to customers and employees.
• Ability to remain calm under pressure and manage stressful situations.
• Ability to maintain a high level of confidentiality and remain HIPAA compliant.
• Ability to establish highly productive and detailed organizational skills/habits.
• Possess strong, professional written and oral communication skills for in-person, telephonic, and electronic use.

tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.