Job Overview
Location
Anywhere in the U.S.
Job Type
Full-time
Category
HR & Recruiting
Date Posted
July 1, 2026
Full Job Description
đź“‹ Description
- • The VP, Provider and Member Appeals & Grievances is an enterprise leader 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, ensuring timely, accurate, and compliant adjudication in accordance with CMS regulations, state requirements, and internal policies.
- • Day to day, the role oversees appeals and grievance intake, routing, clinical reviews, payment dispute resolution, escalation pathways, and final determination issuance; leads root-cause analysis and corrective action planning; develops and enforces quality standards; conducts regular quality checks and case audits; and partners with executive-level teams across Customer Experience, Utilization Management, Clinical, Claims, Non-contracted provider Contracting, and Network Operations to reduce preventable appeals and resolve systemic failures.
- • Alignment Health is a fast-growing company committed to serving seniors and the chronically ill and frail, with a mission to put the senior first; the team is passionate about transforming lives through innovative healthcare solutions, offering ample room for growth and innovation alongside a caring community.
- • In this role, the person will lead and develop a multi-level leadership team of Directors, Senior Managers, and Managers overseeing ~60+ staff; drive organizational design and workforce planning; present enterprise-level performance reports to the C-suite and Board; serve as the primary organizational voice to CMS and regulatory bodies; and drive measurable improvement across quality, timeliness, and member and non-contracted provider outcomes.
🎯 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.
- • Bachelor’s degree in Healthcare Administration, Business, or related field (Master’s degree strongly preferred).
- • Exceptional leadership, communication, and cross-functional collaboration skills, including executive-level influence with C-suite, Board, and regulatory agencies.
- • Experience writing or reviewing medical necessity determinations or complex claim appeals and prior experience participating in or preparing for CMS or NCQA audits.
- • Enterprise budget management and financial accountability, including forecasting, resource planning, and cost optimization.
🏖️ Benefits
- • Opportunity to do work that really matters — changing and saving lives by serving seniors and the chronically ill and frail.
- • Ample room for growth and innovation alongside the Alignment Health community in a fast-growing company.
- • Leadership role with direct accountability for budget, organizational design, and development of Director, Senior Manager, and Manager-level leaders.
- • Primary organizational voice to CMS, external regulatory bodies, and accreditation agencies on appeals and grievances performance, risk, and regulatory strategy.
- • Trusted executive partner translating enterprise business objectives into departmental strategy and driving cross-functional collaboration at the executive level.
Skills & Technologies
See exactly how your profile matches this role — strengths, skill gaps, and what to do about them.
About Alignment Healthcare, LLC
Alignment Healthcare is a health insurance company that focuses on providing personalized care for seniors and underserved populations. They operate a value-based care model, aiming to improve health outcomes and reduce costs through integrated care teams, technology, and data analytics. Their services include Medicare Advantage plans, chronic care management, and home-based care. Alignment Healthcare partners with providers and aims to deliver a seamless and high-quality healthcare experience for its members, emphasizing proactive and preventive care to keep individuals healthy and out of the hospital.
Subscribe to the weekly newsletter for similar remote roles and curated hiring updates.
Newsletter
Weekly remote jobs and featured talent.
No spam. Only curated remote roles and product updates. You can unsubscribe anytime.
Similar Opportunities
2 months ago
Brown & Brown Insurance
6 days ago
Crete Professionals Alliance
3 months ago
Ascertain, Inc.
1 month ago