Associate Vice President, Encounters

Alignment Health•Orange, CA

27d•$198,219 - $297,329

About The Position

The Associate Vice President, Encounters leads Alignment Health's encounter data function and is accountable for the strategy, operating model, controls, and performance needed to deliver complete, accurate, and timely Part C and Part D submissions to CMS; effective reconciliation and remediation; and reliable encounter data capture from delegated and capitated provider groups. Reporting to the Senior Vice President, Claims & Payment Integrity, the AVP translates the broader Claims & Payment Integrity strategy into encounter-specific priorities and leads cross-functional accountability across Claims Operations, Configuration, Technology, Compliance, Finance, Network Management, and delegated oversight. The role focuses on correcting systemic defects at their source rather than managing them only at submission. The AVP is the senior functional leader for encounter data and partners closely with Risk Adjustment, which retains ownership of clinical documentation strategy. The role owns encounter data governance, submission performance, control effectiveness, and identification and escalation of revenue and compliance exposure, while recommending capability, technology, and resource investments to the SVP. The AVP leads through managers and specialized teams and applies strong technical, regulatory, and financial acumen.

Requirements

10+ years of progressive experience in Medicare Advantage encounter data, claims operations, or healthcare data operations, including 5+ years leading teams.
Health plan (payer) experience, including direct ownership of encounter data submission inside a payer organization.
Deep working knowledge of Part C EDPS submission, the 837 lifecycle, CMS response files, and error correction and resubmission.
Experience with MAO-004 reconciliation and identifying and closing gaps between submitted, accepted, and stored data.
Experience collecting and remediating encounter data from delegated or capitated provider groups.
Demonstrated results improving acceptance rates, clearing rejection backlogs, or recovering revenue tied to unsubmitted or rejected encounters.
Executive-level communication skills, including the ability to make a technical data problem understandable to executives and providers.
Bachelor's degree in business, healthcare administration, information systems, finance, or a related field, or an equivalent combination of education and experience.
Able to design and launch a function, including its team, processes, and tools.
Fluent with encounter data, EDI transactions, response files, and reconciliation logic; able to analyze data and direct analysts and engineers. Hands-on coding is not required.
Operational rigor, including reconciling differences and closing the loop rather than accepting a tolerance.
Financial acumen to connect data completeness to dollars and quantify the cost of open error categories.
Ability to hold delegated groups and internal partners accountable to standards while maintaining productive relationships.
Root-cause orientation and ability to fix defects at the source rather than build workarounds at submission.

Nice To Haves

Experience building an encounters function or insourcing encounter operations previously run by a vendor.
Part D prescription drug event (PDE) submission and reconciliation experience.
Experience with chart review and supplemental data submissions, including delete logic.
Experience with Facets or a comparable core claims administration platform.
Experience partnering with a Risk Adjustment organization on revenue opportunity identification.
Master's degree.

Responsibilities

Design and lead the Encounters operating model, including organizational structure, decision rights, governance, control standards, performance routines, and escalation protocols aligned with the broader Claims & Payment Integrity strategy.
Develop and execute the approved capability roadmap, recommending an appropriate mix of internal talent, technology, processes, and vendor support to improve control, scalability, and cost effectiveness.
Establish an encounter performance and risk framework covering submission completeness and timeliness, acceptance and rejection trends, reconciliation status, control effectiveness, delegated-entity performance, and revenue or compliance exposure.
Build and lead a high-performing organization through accountable managers and specialized teams spanning submission operations, data quality, reconciliation, analytics, and delegated-entity performance; develop leadership capability and succession depth.
Provide executive oversight and functional accountability for Part C encounter submissions through EDPS, including the 837 institutional and professional lifecycle, rejection remediation, resubmission processes, and supporting controls.
Establish governance and shared accountability with the pharmacy organization and PBM for Part D prescription drug event submission, reconciliation, error resolution, and timely escalation of material performance or compliance risk.
Ensure disciplined MAO-002 and MAO-004 reconciliation through management controls that identify, prioritize, and remediate material variances between submitted, accepted, stored, and risk-adjustment-eligible data.
Establish governance and control standards for chart review and supplemental data submissions, including adds and deletes, ensuring submissions are accurate, supported, traceable, and coordinated with Risk Adjustment and Compliance.
Hold the organization accountable for an integrated regulatory submission calendar, operational readiness, and timely escalation of risks affecting CMS deadlines, sweep dates, or correction windows.
Set the strategy, standards, and accountability model for obtaining, validating, and submitting encounter data from delegated and capitated provider groups, with remediation and escalation for late, incomplete, or inaccurate data.
Establish enterprise-aligned encounter data requirements, service expectations, scorecards, and governance for delegated entities, ensuring transparent performance reporting and timely corrective action.
Lead cross-functional escalation and remediation with Network Management, Contracting, Compliance, and delegated oversight for material or recurring delegated-entity performance failures; escalate contractual or enterprise-level matters to the SVP as appropriate.
Ensure delegated entities receive actionable performance and root-cause insights and are accountable for sustainable correction of data-quality issues at the source.
Define and govern the encounter data quality framework, including validation standards, error taxonomy, data lineage, root-cause methodology, control monitoring, and executive visibility into systemic defects and exposure.
Establish cross-functional accountability with Claims Operations, Configuration, Technology, and Data teams to prioritize and remediate recurring defects in Facets configuration, intake, adjudication logic, and data interfaces at the source.
Set performance expectations and management controls for rejection inventory, aging, and remediation; hold leaders accountable for sustained backlog prevention and escalate material exposure or resource constraints.
Establish a preventive control environment that detects data-quality and compliance issues before submission and supports audit readiness, issue remediation, and continuous improvement.
Serve as the executive Encounters partner to Risk Adjustment, using complete and accurate encounter data to identify revenue opportunity and exposure, prioritize remediation, and inform financial forecasts while preserving clear functional ownership.
Ensure Risk Adjustment receives reliable, reconciled, decision-ready encounter data and transparent reporting for compliant program targeting and financial analysis.