VP, Provider and Member Appeals – Grievances

🕒 Junho 10

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Alignment Health

SiteLinkedInTodas as Vagas

501 - 1000 funcionários

Fundada em 2013

⚕️ Seguro de Saúde

🛡️ Seguros

🏥 Saúde

💰 $135.000.000 Series C em 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health está comprometida em fornecer cuidados abrangentes para membros do Medicare, enfatizando as necessidades dos idosos, dos cronicamente doentes e daqueles que são frágeis. Com a missão de transformar a saúde dos idosos, a Alignment Health utiliza um modelo de atenção personalizado e tecnologia avançada para oferecer serviços de saúde de alta qualidade e baixo custo. Sua equipe de atendimento de concierge 24 horas por dia, 7 dias por semana, colabora com provedores locais confiáveis para garantir que cada membro receba um atendimento personalizado, refletindo o compromisso da empresa em tratar todos os membros como membros valiosos da família.

Descrição

• Develop and maintain the strategic roadmap for the member and provider appeals program, aligned with Medicare Advantage regulatory requirements and organizational goals • Establish governance structure, oversight routines, and operational policies to ensure compliance with CMS Parts C & D, state statutes, audit readiness, and internal quality standards • Critical representative of the organization in regulatory audits related to appeals, grievances and dispute resolution processes • Own and manage the appeals and grievances operating budget planning, including forecasting, resource planning, and cost optimization. • Lead organizational design and workforce structure for full function, including span of control, leadership layering, and role architecture. • Develop and present enterprise-level performance reports and strategic recommendations to the C-suite and Board as applicable. • Oversee day-to-day operations and staff management of appeals and grievance intake, routing, clinical reviews, payment dispute resolution, escalation pathways, and final determination issuance • Ensure appeals and grievances are resolved within all CMS-mandated timeframes and internal SLAs • Implement standardized workflows, data/dashboards, automation capabilities, and technology solutions to improve accuracy, reduce cycle times, and enhance provider experience • Lead root-cause analysis and corrective action planning for appeal trends, denials, claims edits, and contract disputes • Drives teams to identify process improvements with goal to reduce Provider and member escalations • Ensure all member and provider grievances and appeal decisions comply with CMS Part C regulations, state requirements, and NCQA standards • Collaborate with Compliance and Legal teams to interpret regulatory updates and incorporate them into review and documentation guidelines • Maintain documentation practices that are always “audit-ready” for CMS program audits, ODAG audits, and internal quality reviews • Serve as the primary organizational representative and relationship owner with CMS, state regulatory agencies, and accreditation bodies (NCQA) on matters related to appeals and grievances. • Lead the organization's response to CMS Corrective Action Plans (CAPs), mock audits, and program audit findings related to the appeals and grievances function. • Develop and enforce quality standards for review accuracy, decision rationale, and documentation completeness • Conduct regular quality checks and case audits, identifying patterns of incorrect or inconsistent determinations • Ensure workload inventory for both provider and member efficiently managed to ensure timely actions and resolution • Partner with executive level Customer Experience, Utilization Management, Clinical, Claims, Provider Contracting, and Network Operations to reduce preventable appeals and resolve systemic failures impacting provider satisfaction • Collaborate with Medical Directors and Clinical Operations on medical necessity, coding disputes, and clinical appeal determinations • Work closely with DTS and Data teams to monitor performance, develop dashboards, and predict emerging trends • Lead and develop a multi-level leadership team including Directors, Senior Managers, and Managers responsible for the day-to-day operations of both the provider and member appeals and grievances functions; ensure Director is also managing a small BPO operation. Responsible for the performance, development, and succession planning of all direct and indirect reports across the full department (~60+ staff). Provide coaching and case-level guidance to ensure accurate and defensible determinations • Set expectations for decision quality and serve as a subject matter expert for complex cases • Set expectations for productivity expectations

🎯 Requisitos

• 10+ years of progressive leadership experience in appeals, grievances, utilization management, or health plan regulatory operations, including at least 5 years in a senior leadership role overseeing a multi-functional team in a Medicare Advantage or Health Insurance environment. • Deep understanding of CMS Medicare Advantage Part C requirements and appeal decision standards • Strong experience in case review, documentation, and writing defensible rationales • Excellent clinical and/or analytical judgment and ability to interpret medical records • Experience writing or reviewing medical necessity determinations or complex claim appeals • Prior experience participating in or preparing for CMS or NCQA audits • Exceptional leadership, communication, and cross-functional collaboration skills • Effective written and oral communication skills • Enterprise budget management and financial accountability • Change management and transformation leadership at scale • Vendor and contract management for outsourced or offshore appeals operations • Strategic thinking and long-range planning beyond a 12-month horizon • Data-driven with ability to interpret complex data sets and translate into actionable insights • Organizational design and workforce planning for an Appeals and Grievances function.