VP, Provider and Member Appeals & Grievances

Job Overview 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. 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 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; 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 and performance management Oversee assigned staff, ensuring recruiting, selecting, orienting, training, workload assignment, monitoring, and performance appraisal Job Requirements Experience: 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 Education / Training: Bachelor’s degree in Healthcare Administration, Business, or related field required; Master’s degree (MHA, MBA, MPH) strongly preferred Specialized Skills: Exceptional leadership, communication, and cross-functional collaboration skills; executive-level influence and communication with C‑suite, Board, and 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 ability to interpret complex data sets and translate into actionable insights; organizational design and workforce planning for an Appeals and Grievances function Licensure: N/A (Preferred N/A) Physical Functions Regularly required to talk or hear Regularly required to stand, walk, sit, use hands to finger, handle or feel objects, tools, or controls, and reach with hands and arms Frequently lifts and/or moves up to 10 pounds Specific vision abilities required: close vision and ability to adjust focus Pay Range $227,952.00 - $341,928.00 Equal Opportunity/Affirmative Action 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. #J-18808-Ljbffr E2E Alignment Healthcare USA, LLC