Associate Vice President, Claim Payment Accuracy

Alignment Health•Orange, CA

3d•$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 position. The AVP leads cross-functional work from identifying signals and root causes through corrective action, validation, and sustained control. The role partners across Payment Integrity, Claim Audit, Claim Operations, Configuration, Technology, Data, Finance, Compliance, Network, and other claim-adjacent functions. Its goal is to reduce avoidable payment leakage and systematically decrease reliance on retrospective Payment Integrity recovery by correcting upstream process, configuration, data, policy, and technology defects. FWA activities may be housed within the organization, while the AVP remains accountable for the broader claim payment accuracy agenda. The AVP defines the enterprise strategy, operating model, governance, and multiyear roadmap; develops analytics-led identification and prioritization of systemic payment defects; and drives funded, cross-functional remediation through implementation, validation, and sustained monitoring. The role also leads governance and executive reporting, provides oversight for FWA work housed within the function, and builds the organization, team, skills, and analytical capacity needed to manage the agenda. The position requires a bachelor's degree in a relevant field or an equivalent combination of education and experience. A master's degree and relevant professional certifications are preferred. The stated pay range is $198,219.00–$297,329.00; pay may depend on factors including market location, education, responsibilities, and experience. The role's physical functions include regularly talking or hearing, standing, walking, sitting, handling or feeling objects, tools, or controls, reaching with hands and arms, and frequently lifting or moving up to 10 pounds. Reasonable accommodations may be made for individuals with disabilities.

Requirements

At least 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.
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.
Required licensure or certification: none.
Ability to regularly talk or hear, stand, walk, sit, use hands and fingers, handle or feel objects, tools, or controls, and reach with hands and arms.
Ability to frequently lift and/or move up to 10 pounds; close vision and ability to adjust focus are required.

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.
Establish a transparent portfolio of known and emerging payment issues across prepay, postpay, audit, operations, configuration, provider, and FWA signals.
Create consistent methods 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 housed within the function and coordinate 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 turn audit results into enterprise learning and corrective action.
Partner with Claim Operations to design practical changes that improve accuracy without unnecessary operational burden or 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 needed 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.