VP, Provider and Member Appeals & Grievances

Benefits

Additional Information

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. The VP, Provider and Member Appeals and Grievances is an enterprise leader accountable for the full strategic, operational, regulatory, and people management functions of Alignment Health's provider and member appeals, grievances, and CTM programs. This role owns the end-to-end performance of both functions - ensuring timely, accurate, and compliant adjudication of provider and member payment disputes, coverage appeals, clinical appeals, and administrative reviews in accordance with CMS regu-lations, state requirements, and internal policies. Operating at the intersection of regulatory compliance, operational excellence, and member experi-ence, this leader is responsible for building and sustaining a high-performing, multi-layered leadership organization that drives Caring Connections, proactively manages compliance risk, and delivers meas-urable improvement across quality, timeliness, and member and provider outcomes. This role carries direct accountability for budget accountability, organizational design, and the development of Director, Senior Manager, and Manager-level leaders within the function. The VP serves as Alignment Health's primary organizational voice to CMS, external regulatory bodies, and accreditation agencies on all matters related to appeals and grievances performance, risk, and reg-ulatory strategy. Internally, this leader is a trusted executive partner - translating enterprise business objectives into departmental strategy, presenting performance and risk outcomes to senior leadership, and driving cross-functional collaboration at the executive level to resolve systemic issues and prevent avoidable appeals and grievances at scale. Job Responsibilities: Strategic Leadership & Governance 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. Operational Excellence 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 Regulatory & Compliance Alignment 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. Quality Assurance & Decision Consistency 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 inco