Director, Claims Audit

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October 28

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Alignment Health

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Healthcare Insurance • Insurance • Healthcare

Alignment Health is dedicated to providing comprehensive care for Medicare members, emphasizing the needs of seniors, the chronically ill, and those who are frail. With a mission to transform senior healthcare, Alignment Health leverages a tailored care model and advanced technology to deliver high-quality, low-cost healthcare services. Their 24/7 concierge care team collaborates with trusted local providers to ensure that every member receives personalized care, reflecting the company's commitment to treating all members as valued family members.

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

💰 $135M Series C on 2020-03

📋 Description

• Lead the design, execution, and continuous improvement of internal claims audit activities, including monitoring, tracking, root cause analysis, and issue resolution. • Ensure compliance with CMS regulations, SOX requirements, and other applicable federal and state mandates; serve as a liaison with Compliance, Legal, and Finance to maintain audit process integrity and readiness. • Oversee preparation and delivery of monthly, quarterly, and ad hoc reporting packages for senior leadership, Audit Committees, and external auditors, including internal audit control reviews and PWC discussions. • Provide data-driven insights by compiling and analyzing claims audit metrics, trends, and variance drivers; develop actionable recommendations to mitigate risks and support operational decision-making. • Partner with Claims Optimization and Operations teams to identify recurring audit issues, performance gaps, or anomalies, and translate findings into sustainable process improvements. • Collaborate cross-functionally to design and implement corrective action plans (CAPs), report cards, and long-term operational solutions that reduce audit findings and enhance efficiency. • Manage weekly audit monitoring reports, engage with BPO partners and internal teams to resolve findings, and track corrective action progress. • Contribute to enterprise-level presentations and initiatives by preparing audit-related insights, analyses, and operational performance updates. • Support other departmental or enterprise priorities as assigned, adapting to evolving business needs.

🎯 Requirements

• 10+ years of experience in health plan operations, claims auditing, compliance, or process optimization. • 4+ years in a leadership role, managing cross-functional teams or enterprise-level initiatives. • Demonstrated expertise in CMS regulations, SOX, audit committee reporting, and internal/external audits (e.g., PWC, CMS). • Proven track record of leading initiatives that reduced manual effort, resolved high-volume claim categories, and improved operational efficiency. • Strong understanding of the claims lifecycle, audit principles, and regulatory compliance, with the ability to translate findings into actionable operational improvements. • Strategic thinker with the ability to influence and partner across multiple departments to drive change and optimize processes. • Advanced analytical and reporting skills, including experience with Excel, SQL, and data visualization tools (Power BI, Tableau, or similar). • Excellent communication and presentation skills, capable of engaging executives, auditors, and operational teams. • Demonstrated ability to lead change, prioritize competing initiatives, and operate effectively in a complex, high-visibility environment. • Bachelor's degree required (Healthcare Administration, Business, Healthcare Management, or related field); or equivalent combination of education and experience. • Master's degree (MBA, MHA) preferred. • Intermediate to Advance proficiency in MS Office products – Word, Access, PowerPoint, Visio and Excel. • Preferred: Proficiency in data analysis tools such as Excel or SQL; visualization experience a plus. • Hands-on experience working with the claims system, Facets claims system a strong plus.

🏖️ Benefits

• None specified