Associate Vice President, Claim Payment Accuracy

Alignment Healthcare•Orange, CA

1d•$198,219 - $297,329

About The Position

The Associate Vice President, Claim Payment Accuracy owns Alignment Health’s enterprise discipline for identifying, prioritizing, and permanently remediating issues that cause claims to pay incorrectly. This is an operational excellence and transformation role rather than a day-to-day claims production or quality assurance role. The AVP leads cross-functional work from signal identification and root-cause analysis through corrective action, validation, and sustained control, partnering with Payment Integrity, Claim Audit, Claim Operations, Configuration, Technology, Data, Finance, Compliance, Network, and other claim-adjacent functions. The role’s aim is to reduce avoidable payment leakage and reliance on retrospective Payment Integrity recovery by fixing upstream process, configuration, data, policy, and technology defects. The AVP may oversee Fraud, Waste, and Abuse (FWA) activities within the organization, while remaining accountable for the broader claim payment accuracy agenda. The AVP defines the enterprise strategy, operating model, governance, and multiyear roadmap for claim payment accuracy; maintains a transparent portfolio of known and emerging payment issues; and establishes methods for sizing, prioritizing, and sequencing issues. The role builds an analytics-led capability to identify systemic payment defects, translate findings into actionable fixes, and measure accuracy, recurrence, remediation time, prevented loss, and sustained financial impact. It directs structured root-cause analysis and coordinates funded remediation plans across functions, validating fixes and monitoring whether results persist. The position also provides oversight for FWA work within the function, leads cross-functional governance, communicates exposure and progress to executive leadership, and builds the organization, team, analytical capacity, and culture needed to manage the agenda. Success requires analytical strength, disciplined problem solving, executive communication and influence, and the ability to drive change across teams without relying solely on direct authority.

Requirements

10+ years of progressive experience in health plan claims, payment integrity, operational excellence, enterprise transformation, analytics, audit, or a related discipline.
At least 5 years leading teams or complex cross-functional programs.
Health plan payer experience and a strong understanding of end-to-end claim payment processes and upstream factors affecting payment accuracy.
Demonstrated success identifying systemic problems, conducting or directing root-cause analysis, and driving corrective action across multiple functions.
Strong analytical orientation and experience using claims, financial, operational, or audit data to size problems, prioritize work, and validate outcomes.
Experience establishing governance, portfolio management, and executive reporting for complex remediation or transformation initiatives.
Proven ability to influence senior leaders, resolve competing priorities, and maintain accountability across teams without direct reporting authority.
Executive-level communication skills, including simplifying complex issues, quantifying impact, recommending decisions, and communicating risk.
Bachelor’s degree in business, healthcare administration, analytics, finance, information systems, engineering, or a related field, or an equivalent combination of education and experience.
Systems thinking: connect downstream payment outcomes to upstream process, policy, configuration, data, technology, and provider causes.
Analytical leadership: frame questions, test assumptions, size exposure, evaluate methods, and convert data into decisions.
Operational excellence mindset: build repeatable mechanisms that eliminate defects at the source rather than managing recurring symptoms.
Transformation leadership: move cross-functional work from diagnosis through implementation, validation, and sustained adoption.
Enterprise influence: create alignment, clarify accountability, and drive decisions across organizational boundaries.
Financial discipline: distinguish identified, recovered, avoided, and validated value and ensure benefits are credible and traceable.
Pragmatic judgment: balance speed, risk, member and provider impact, operational feasibility, and long-term durability.
Clear communication: present complex claim payment issues concisely for executives with a specific decision or action.
Required licensure or certification: none.

Nice To Haves

Medicare Advantage and CMS claim payment experience.
Experience leading an analytics, payment accuracy, claims transformation, operational excellence, or enterprise remediation function.
Working knowledge of healthcare reimbursement, claim configuration, payment policy, provider data, and core claims administration platforms.
Experience with Facets or a comparable core claims administration platform.
Familiarity with data visualization, SQL, statistical analysis, process improvement, or automation tools; direct technical execution is not required.
Master’s degree.
Lean, Six Sigma, process improvement, project or program management, analytics, or related certification.

Responsibilities

Define and lead the enterprise claim payment accuracy strategy, operating model, governance, and multiyear roadmap.
Maintain a single, transparent portfolio of known and emerging payment issues across prepay, postpay, audit, operations, configuration, provider, and FWA signals.
Establish a consistent method to size, prioritize, and sequence issues based on financial exposure, member and provider impact, compliance risk, recurrence, and remediation complexity.
Define accountability, decision rights, escalation paths, and closure criteria for cross-functional remediation work.
Build and direct an analytics-led capability connecting recovery, audit, adjustment, denial, configuration, provider, and operational data to identify systemic payment defects.
Translate Payment Integrity recoveries and Claim Audit findings into root-cause themes, quantified exposure, and actionable upstream fixes.
Distinguish isolated errors from recurring patterns and enterprise defects, and focus resources on issues with the greatest preventable value.
Develop measures for payment accuracy, defect recurrence, time to remediation, prevented loss, and sustained financial impact.
Partner with Data and Technology teams to improve data availability, traceability, and analytical tooling; challenge methods, interpret results, and direct analysts.
Lead structured root-cause analysis across people, process, policy, configuration, data, vendor, and technology dimensions.
Convert findings into funded, owned remediation plans with milestones, dependencies, controls, and measurable outcomes.
Coordinate implementation across Claim Operations, Configuration, Product, Technology, Payment Integrity, Claim Audit, Finance, Network, and other impacted functions.
Validate fixes, quantify prevented value, monitor recurrence, and reopen issues when results are not sustained.
Ensure temporary containment is used when necessary while durable upstream corrections are designed and implemented.
Provide leadership oversight for FWA work within the function and coordinate it with Compliance, Legal, Payment Integrity, Network, and Claim Operations.
Ensure substantiated FWA patterns inform preventive controls, payment policy, provider action, and broader remediation priorities.
Maintain clear handoffs for regulatory, investigative, recovery, and operational remediation responsibilities without duplicating Compliance accountability.
Chair or lead governance forums to review the payment accuracy portfolio, remove barriers, assign ownership, and make prioritization decisions.
Partner with Payment Integrity to turn retrospective findings into prospective prevention and avoid duplicate or conflicting interventions.
Partner with Claim Audit to translate audit results into enterprise learning and corrective action.
Partner with Claim Operations to design practical changes that improve accuracy without unnecessary operational burden or avoidable disruption.
Communicate exposure, decisions, progress, realized and prevented value, and unresolved risk to the SVP, Claims & Payment Integrity and executive leadership.
Design the organization, roles, skills, routines, and analytical capacity required to manage the payment accuracy agenda.
Recruit, develop, and lead a team that may include analytics, root-cause, program leadership, and FWA capabilities.
Create a culture of fact-based problem solving, ownership, urgency, transparency, and durable resolution.