Chief Medical Officer, Payment Integrity

At Zelis, we Get Stuff Done. So, let's get to it!

A Little About Us

Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients.

At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.

A Little About You

You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.

Position Overview

What You'll Bring:

Clinical Leadership & Expertise

• Serve as the senior clinical authority for Payment Integrity solutions, including Claims Editing and Expert Claim Review.

• Guide the enhancement of current products through clinical insight, coding expertise, and interpretation of billing, reimbursement, and operational standards.

• Provide expertise in the application of Medicare, Medicaid, and commercial payer rules, regulations, policies, and procedures.

• Participate in physician peer review activities and support clinical governance processes.

• Partner with Product, Analytics, and Operations teams to translate clinical variation into measurable risk signals and scalable claims logic.

• Evaluate model outputs and workflows for clinical appropriateness, operational feasibility, and provider impact.

• Deliver clinical guidance related to provider appeals and support development and review of appeal responses.

• Communicate complex clinical concepts and rationale clearly to both clinical and non-clinical audiences.

• Support client policy initiatives and adoption of new clinical policies, methodologies, and tools.

• Maintain current knowledge of healthcare delivery trends, reimbursement policy, coding practices, regulatory developments, and technologies impacting payment integrity.

Strategic Leadership & Market Influence

• Define and advance the clinical strategy for Payment Integrity in alignment with Zelis' business objectives and client priorities.

• Influence product roadmap decisions, including opportunities for automation, clinical review optimization, and policy evolution.

• Balance accuracy, savings, provider experience, operational efficiency, and scalability in strategic decision-making.

• Assess competitive market dynamics, emerging industry trends, and evolving payer/provider challenges.

• Serve as an executive advisor and trusted partner to clients, prospective clients, and internal stakeholders.

• Support Sales and Client teams in executive-level presentations, strategic discussions, and solution positioning.

• Represent Zelis as an industry thought leader through speaking engagements, conferences, published content, and participation in industry forums.

• Contribute to strategic initiatives, partnerships, and acquisition-related diligence activities as needed.

• Lead through influence and collaboration across business units and executive stakeholders.

What You'll Bring:

Required Qualifications

• MD or DO degree with current board certification.

• Broad clinical experience with strong understanding of healthcare delivery and reimbursement models.

• Deep knowledge of commercial payer, Medicare, and Medicaid reimbursement methodologies, policies, and regulations.

• Experience within a payer, payment integrity, utilization management, healthcare technology, consulting, or related healthcare services environment.

• Demonstrated experience translating clinical expertise into operational, analytical, or technology-enabled solutions.

• Executive-level communication and presentation skills, including experience engaging clients, providers, and senior business leaders.

• Proven ability to influence cross-functional stakeholders and lead through collaboration in a matrixed environment.

Preferred Qualifications

• Experience in payment integrity, claims editing, coding compliance, or healthcare cost management.

• Familiarity with data analytics, AI-enabled workflows, and scalable clinical decision-support methodologies.

• Prior experience representing an organization externally through conferences, publications, or industry leadership activities.

Leadership Competencies

The successful candidate will demonstrate:

• Executive presence with the ability to build credibility and trust across clinical, operational, technical, and commercial audiences.

• Sound judgment, integrity, and a strong commitment to ethical and clinically responsible decision-making.

• Strategic thinking balanced with operational pragmatism and execution focus.

• Diplomacy and influence skills, particularly in navigating complex stakeholder environments.

• Strong collaboration skills with the ability to lead through influence rather than direct authority.

• Comfort operating in a fast-paced, evolving, and highly matrixed organization.

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.

Location and Workplace Flexibility

Zelis is headquartered in the U.S., with multiple locations across the country and in Hyderabad, India. Check out our locations to learn more about our offices. All employee work locations are based on the needs of the position and are determined by the Leadership team. In-office work and activities vary based on work and team objectives in accordance with Company policies.

While location expectations vary by role, candidates within approximately 50 miles of a U.S. office are generally preferred to support collaboration when needed. Our hybrid approach is flexible, and in-office presence is guided by team and business needs rather than a fixed weekly schedule.

Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment 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.

We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.

Accessibility Support
We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.