AVP, Care Anywhere (High Risk Case Management)

Alignment Health

About The Position

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 AVP of Care Anywhere provides strategic and operational leadership for enterprise-wide complex case management programs serving the most clinically vulnerable Medicare Advantage members, including those with advanced illness, frailty, poly-chronic conditions, and end-of-life needs. This role is accountable for driving measurable improvements in quality outcomes, total cost of care, utilization efficiency, member experience, and risk adjustment accuracy, while ensuring compassionate, person-centered care aligned with member goals and regulatory expectations. The AVP partners closely with Clinical Operations, Medical Directors, Quality, Risk Adjustment, Network, Analytics, and Vendor Management to design and scale high-impact interventions for high-cost, high-risk populations.

Requirements

8+ years of progressive leadership experience in case management, population health, or medical management, with at least 5 years at a senior leadership level.
Deep experience with Medicare Advantage, including CMS regulations, Stars, HEDIS, and MA quality frameworks.
Demonstrated expertise in complex care management, high-risk populations, palliative care, and/or end-of-life care.
Strong understanding of utilization management, total cost of care drivers, and value-based care models.
Working knowledge of risk adjustment (HCCs) and clinical documentation improvement in MA populations.
Proven ability to lead large, distributed clinical teams and influence across matrixed organizations.
Master’s degree in Healthcare Administration, Public Health, or related field
Deep understanding of CMS STAR measures and Medicare Advantage regulatory requirements.
Strong knowledge of clinical operations, care management, and population health models.
Ability to translate regulatory and quality standards into practical clinical workflows.
Exceptional leadership, collaboration, and influencing skills.
Data-driven mindset with the ability to interpret performance metrics and drive action.
Excellent communication and executive presentation skills.

Nice To Haves

Master’s degree Clinical licensure (e.g., RN, NP, MD, DO).
Lean Six Sigma, other processes improvement certification, Certified Professional in Healthcare Quality (CPHQ), or Certified Professional in Healthcare Management (CPHM)

Responsibilities

Strategic Leadership & Program Design Set the enterprise strategy for Care Anywhere / Complex Case Management focused on high-risk, rising-risk, and end-of-life Medicare Advantage members.
Design and evolve advanced illness, palliative, and end-of-life case management models that integrate medical, behavioral, social, and caregiver needs.
Ensure programs align with CMS requirements, MA Star Ratings, HEDIS, CAHPS, and evolving end-of-life best practices.
Serve as a thought leader on serious illness care, goals-of-care planning, and appropriate utilization across the continuum.
Quality Outcomes & Member Experience Drive improvement in clinical quality metrics, including chronic condition management, transitions of care, medication adherence, and end-of-life quality indicators.
Embed advance care planning, POLST/MOLST documentation, and goals-of-care conversations into standard workflows.
Partner with Quality and Stars teams to optimize performance in measures impacted by high-risk populations.
Champion a member- and caregiver-centered approach, improving satisfaction and reducing care fragmentation.
Utilization Management & Cost of Care Lead initiatives to reduce avoidable inpatient admissions, readmissions, ER utilization, and non-beneficial care at end of life.
Collaborate with Medical Directors and Clinical leaders to ensure appropriate intensity of care, hospice and palliative referrals, and site-of-care optimization.
Use data-driven insights to target high-cost outliers and deploy intensive interventions at the right time.
Ensure care delivery balances clinical appropriateness, member preferences, and financial stewardship.
Risk Adjustment & Documentation Excellence Partner with Risk Adjustment teams to ensure accurate, compliant documentation of disease acuity and severity in complex and end-of-life populations.
Integrate case management workflows with HCC capture, suspect condition validation, and provider documentation improvement efforts.
Educate clinical teams on the intersection of complex care, end-of-life care, and risk adjustment accuracy without compromising care integrity.
Operational Leadership & Team Development Provide executive oversight for national teams of complex case managers, clinical leads, and vendor partners.
Establish performance standards, KPIs, and outcomes dashboards for complex case management programs.
Build scalable staffing models that support intensity-based care management.
Mentor and develop clinical leaders, fostering a culture of accountability, compassion, and continuous improvement.
Cross-Functional & External Partnerships Collaborate with Network, Provider Engagement, and Value-Based Care teams to align complex case management with provider workflows.
Oversee relationships with palliative care, hospice, home health, and community-based organizations.
Support innovation pilots, vendor evaluations, and expansion of alternative care models for advanced illness populations.