VP, Provider and Member Appeals & Grievances

Alignment Health • Remote CA Outside Bay Area, CA

58d • $227,952 - $341,928 • Onsite

About The Position

Alignment Health is seeking a VP, Appeals and Grievances for Non-Contracted provider Appeals and Member Appeals and Grievances. This enterprise leader will be accountable for the full strategic, operational, regulatory, and people management functions of Alignment Health's non-contracted provider and member appeals, grievances, and CTM programs. The role owns the end-to-end performance of both functions, ensuring timely, accurate, and compliant adjudication of non-contracted provider and member payment coverage appeals, clinical appeals, and administrative reviews in accordance with CMS regulations, state requirements, and internal policies. Operating at the intersection of regulatory compliance, operational excellence, and member experience, 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 measurable improvement across quality, timeliness, and member and non-contracted 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 regulatory 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.

Requirements

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

Nice To Haves

• Board or executive level presentation experience.
• Master’s degree (MHA, MBA, MPH is strongly preferred).

Responsibilities

• Develop and maintain the strategic roadmap for the member and non-contracted 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.
• Serve as a critical representative of the organization in regulatory audits related to appeals and grievances 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.
• 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 non-contracted provider experience.
• Lead root-cause analysis and corrective action planning for appeal trends, claims edits, and contract disputes.
• Drive teams to identify process improvements with the goal to reduce non-contracted provider and member escalations.
• Ensure all member and non-contracted 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.
• 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 non-contracted provider and member is efficiently managed to ensure timely actions and resolution.
• Partner with executive-level Customer Experience, Utilization Management, Clinical, Claims, Non-contracted provider Contracting, and Network Operations to reduce preventable appeals and resolve systemic failures impacting non-contracted 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.
• Lead and develop a multi-level leadership team including Directors, Senior Managers, and Managers responsible for the day-to-day operations of both the non-contracted provider and member appeals and grievances functions; ensure Director is also managing a 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.
• Oversee 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.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Executive