VP, Provider and Member Appeals – Grievances

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Alignment Health

WebsiteLinkedInAlle Stellen

501 - 1000 Mitarbeiter

Gegründet 2013

⚕️ Krankenversicherung

🛡️ Versicherung

🏥 Gesundheitswesen

💰 €135.000.000 Series C im 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health engagiert sich für die Bereitstellung umfassender Pflege für Medicare-Mitglieder, wobei der Fokus auf den Bedürfnissen von Senioren, chronisch Kranken und gebrechlichen Personen liegt. Mit der Mission, das Gesundheitswesen für Senioren zu transformieren, nutzt Alignment Health ein maßgeschneidertes Pflegemodell und fortschrittliche Technologie, um qualitativ hochwertige, kostengünstige Gesundheitsdienstleistungen anzubieten. Ihr 24/7-Konzierge-Pflegeteam arbeitet mit vertrauenswürdigen lokalen Anbietern zusammen, um sicherzustellen, dass jedes Mitglied eine individuelle Betreuung erhält, was das Engagement des Unternehmens widerspiegelt, alle Mitglieder als geschätzte Familienmitglieder zu behandeln.

Beschreibung

• 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

🎯 Anforderungen

• 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.