VP, Provider and Member Appeals & Grievances

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 inconsistent determinations
• Ensure workload inventory for both provider and member 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 expectations

Supervisory Responsibilities:

• Oversees assigned staff. Responsibilities include ensuring leadership team driving: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and performance management

Job Requirements:

Experience:

Required:

• 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

Preferred:

• Board or executive level presentation experience

Education / Training:

Required:

• Bachelor’s degree in Healthcare Administration, Business, or related field

Preferred:

• Master’s degree (MHA, MBA, MPH is strongly preferred)

Specialized Skills:

Required:

• 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 ability to interpret complex data sets and translate into actionable insights
• Organizational design and workforce planning for an Appeals and Grievances function

Licensure:

Required: N/A

Preferred: N/A

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. 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.

2. 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.

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.