Senior Vice President, Claims Services and Solutions

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Senior Vice President, Claims Services and Solutions based in the United States.

This is a senior executive opportunity to lead and transform a large-scale healthcare payer claims services organization serving health plans nationwide. The role combines operational leadership, strategic solution development, executive client engagement, technology enablement, and business growth. You will shape the future operating model for claims services while driving improvements in quality, productivity, turnaround times, service levels, and financial performance. The position partners closely with Sales, Client Services, Technology, Product, and Executive Leadership to develop innovative, scalable solutions for complex payer environments. A key focus will be modernizing claims operations through workflow optimization, automation, analytics, AI-enabled quality processes, and disciplined governance. You will also play a highly visible role with executive clients, strengthening relationships, supporting growth opportunities, and leading operational recovery and stabilization initiatives. This is an opportunity for an accomplished healthcare claims executive to have measurable influence on client outcomes, employee performance, operational excellence, and long-term business growth.

Accountabilities:: Provide overall executive leadership for the healthcare payer Claims Services organization, establishing strategic direction, operating priorities, performance standards, and long-term growth plans.

Build and scale a high-performing, multi-client claims operating model covering the full lifecycle from claim receipt and intake through adjudication, quality review, release, and final disposition.

Drive operational excellence across quality, turnaround time, productivity, inventory, pends, backlog, workforce readiness, and client service-level commitments.

Lead operational turnaround and stabilization initiatives for complex, underperforming, or high-risk claims environments, restoring performance and client confidence.

Establish rigorous quality assurance, audit, root-cause analysis, coaching, release controls, and error-reduction practices.

Develop disciplined claims rule governance, operational knowledge management, version-controlled client instructions, and single-source-of-truth practices.

Partner with Technology and Product leadership to translate claims requirements into workflow, routing, dashboard, audit, knowledge management, automation, and AI-enabled quality solutions.

Lead executive-level client relationships, including quarterly business reviews, governance meetings, steering committees, escalations, renewal discussions, recovery plans, and operational performance reviews.

Partner with Sales, Account Management, and Client Services on RFPs, RFIs, discovery sessions, solution design, staffing models, pricing assumptions, statements of work, finalist presentations, renewals, and expansion opportunities.

Own financial and operating performance, including budgets, labor utilization, productivity economics, cost of quality, margin improvement, investment decisions, and resource allocation.

Develop and maintain a strong claims leadership organization capable of supporting growth, managing complex client requirements, and consistently meeting service commitments.

Coach and develop senior leaders while fostering a culture of accountability, continuous improvement, collaboration, operational discipline, and client focus.

Identify opportunities to modernize claims administration through technology, automation, analytics, and AI while maintaining appropriate quality, compliance, and operational controls.

Use performance data and client feedback to establish improvement priorities and ensure measurable progress across service delivery, quality, efficiency, and customer satisfaction.

Contribute to the broader business strategy by identifying market opportunities, strengthening service offerings, and helping shape the future of technology-enabled claims administration.

Requirements

15+ years of progressive experience in healthcare payer claims, including claims processing, adjudication, complex claims, quality, productivity, service-level management, and operational performance.

10+ years of leadership experience in claims operations, claims services, claims delivery, or claims transformation within a healthcare payer BPO, outsourcing, managed services, BPaaS, payer administrative services, or comparable client-services environment.

Demonstrated success improving claims quality, reducing backlog and aging, increasing productivity, stabilizing operations, and rebuilding or strengthening client confidence.

Extensive end-to-end knowledge of claims processes, including intake, assignment, workflow management, pends, adjudication, quality assurance, release governance, reporting, escalation, and final disposition.

Meaningful experience supporting California healthcare payer markets , including California-based health plans, Medi-Cal programs, managed care organizations, claims administration services, delegated services models, payer administrative services, or comparable California payer environments.

Proven executive-level client relationship experience, including QBRs, governance meetings, steering committees, executive escalations, renewal support, recovery conversations, and strategic account management.

Experience contributing to business growth through RFPs, RFIs, solution design, staffing models, pricing, statements of work, finalist presentations, renewals, and client expansion opportunities.

Strong financial and operational management capabilities, including labor utilization, staffing economics, cost of quality, productivity, margin management, budgeting, and investment tradeoffs.

Ability to translate complex claims operating requirements into practical technology, workflow, analytics, automation, and quality-control solutions.

Strong understanding of healthcare payer operations, claims administration, service delivery, and the evolving technology landscape supporting these functions.

Demonstrated ability to lead large, complex, multi-client operations while balancing service quality, financial performance, workforce requirements, and client expectations.

Exceptional executive communication and presentation skills, with the credibility to engage senior leaders and influence decisions across internal and external organizations.

Strong strategic thinking combined with hands-on operational discipline and a bias toward measurable results.

Proven ability to build, coach, and retain high-performing leadership teams in complex, fast-paced environments.

Strong relationship-building, negotiation, problem-solving, decision-making, and change-management skills.

Ability to operate effectively in a remote leadership environment while collaborating across geographically distributed teams.

Benefits

Competitive executive-level compensation aligned with the scope and seniority of the position.

Fully remote position based in the United States.

Opportunity to lead a strategically important healthcare payer services organization during a period of growth and transformation.

Significant executive visibility and influence over claims strategy, operating models, technology modernization, client experience, and business growth.

Opportunity to work closely with senior leaders across Sales, Client Services, Technology, Product, and Executive Leadership.

Ability to shape technology-enabled claims solutions incorporating automation, analytics, workflow modernization, and AI.

Opportunity to build and develop a high-performing leadership organization.

Direct impact on operational performance, client satisfaction, employee engagement, and long-term business results.

Comprehensive employee benefits and programs, subject to applicable plan terms and eligibility.

How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best!  Why Apply Through Jobgether?    Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.     #LI-CL1