[Hiring] VP, Provider and Member Appeals & Grievances @Alignment Health

Role Description

The VP, Appeals and Grievances for Non-Contracted provider Appeals and Member Appeals and 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. This 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.

• 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.
• 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.
• 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.
• Ensure all member and non-contracted provider grievances and appeal decisions comply with CMS Part C regulations, state requirements, and NCQA standards.
• Develop and enforce quality standards for review accuracy, decision rationale, and documentation completeness.
• 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.

Qualifications

• 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.

Requirements

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

Benefits

• Pay Range: $227,952.00 - $341,928.00.
• Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.