VP, Provider and Member Appeals, Grievances

🕒 June 19

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

👥 B2C

💰 $321.1M Post-IPO Debt - Alignment Health on 2024-11

Healthcare Insurance • B2C

Alignment Health is a Medicare-focused health insurance company that offers Medicare Advantage plans and member-centered services. It provides 24/7 on-demand access to care via in-person, in-home, and mobile channels and features a concierge-style on-demand card to help members schedule appointments, arrange transportation, and answer health questions. Alignment Health partners with brokers, providers, Accountable Care Organizations (ACOs), and institutional partners, operates in multiple U. S. states (including Arizona, California, Nevada, North Carolina, and Texas), and has earned high CMS ratings and industry recognition.

📋 Description

• Develop and maintain the strategic roadmap for the member and non-contracted provider appeals program • Establish governance structure, oversight routines, and operational policies to ensure compliance with CMS Parts C & D, state statutes, audit readiness, and internal quality standards • Lead organizational design and workforce structure for full function • 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 • Collaborate with Compliance and Legal teams to interpret regulatory updates and incorporate them into review and documentation guidelines • Develop and enforce quality standards for review accuracy, decision rationale, and documentation completeness • Lead and develop a multi-level leadership team including Directors, Senior Managers, and Managers responsible for the day-to-day operations • Set expectations for decision quality and serve as a subject matter expert for complex cases

🎯 Requirements

• 10+ years of progressive leadership experience in appeals, grievances, utilization management, or health plan regulatory operations • 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 • Bachelor’s degree in Healthcare Administration, Business, or related field

🏖️ Benefits

• Health insurance • Professional development opportunities