VP, Provider and Member Appeals & Grievances
Location
United States
Posted
38 days ago
Salary
$228.0K - $341.9K / year
Seniority
Mid Level
No structured requirement data.
Job Description
VP, Provider and Member Appeals & Grievances
Alignment Health
Role Description 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 regulations, state requirements, and internal policies. Operating at the intersection of regulatory compliance, operational excellence, and member experience, 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 measurable 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 regulatory strategy. 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. - Drive teams to identify process improvements with the 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 inconsistent determinations. - Ensure workload inventory for both provider and member is efficiently managed to ensure timely actions and resolution. - Cross-Functional Collaboration - 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. - Team Leadership - 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. - 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. Requirements - 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. Education / Training - Bachelor’s degree in Healthcare Administration, Business, or related field. - Master’s degree (MHA, MBA, MPH is strongly preferred). Specialized Skills - Exceptional leadership, communication, and cross-functional collaboration skills. - Effective written and oral communication skills. - Executive-level influence and communication (C-suite, Board, regulatory agencies). - 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 the ability to interpret complex data sets and translate into actionable insights. - Organizational design and workforce planning for an Appeals and Grievances function. Essential Physical Functions - While performing the duties of this job, the employee is regularly required to talk or hear. - The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. - The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. Pay Range $227,952.00 - $341,928.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. Equal Opportunity Employer Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation. Disclaimer Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/ . If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com .
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