VP Claims Optimization

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 fastgrowing 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.

We are seeking an experienced Senior Operational Leader to oversee and enhance our claims configuration provider payment optimization and payment integrity operations. The successful candidate will be responsible for building and leading a highperforming team driving strategic initiatives and delivering analytical insights to support decisionmaking and growth. This role demands a blend of operational expertise leadership skills and strategic vision to optimize our claims and payment processes and ensure the highest quality and efficiency in our operations.

Job Duties/Responsibilities:

1 Configuration:

• Oversee the development implementation and management of configuration for provider contracts member plan benefits and division of operational responsibility in order to pay claims accurately.
• Ensure accurate and timely configuration in the system.
• Collaborate with internal and external stakeholders to resolve contractrelated issues and optimize contract terms.

2 Optimization Strategy:

• Lead initiatives to enhance autoadjudication processes ensuring accuracy and efficiency.
• Monitor and analyze autoadjudication performance metrics implementing improvements as needed.
• Work with IT and system development teams to refine adjudication algorithms and rules.

3 Payment Integrity (Pre and Post Payment):

• Develop and manage prepayment and postpayment integrity strategies to prevent fraud waste and abuse.
• Implement and oversee audit processes to ensure payment accuracy and compliance.
• Collaborate with finance and compliance teams to address and resolve payment discrepancies.

4 Claims Quality Audit:

• Design and execute a comprehensive claims quality audit program to assess and improve claims processing accuracy.
• Analyze audit results and develop action plans to address identified issues.
• Ensure audit processes align with industry standards and regulatory requirements.

5 Team Building and Leadership:

• Build mentor and lead a team of operational professionals to drive performance and achieve departmental goals.
• Foster a collaborative and innovative work environment.
• Provide training and development opportunities to enhance team capabilities and career growth.

6 Analytical Insights and Strategic DecisionMaking:

• Utilize data analytics to provide actionable insights and support strategic decisionmaking.
• Develop and present reports and recommendations to senior leadership based on operational performance and market trends.
• Drive continuous improvement initiatives based on analytical findings and business needs.

Supervisory Requirements:

Fulfill supervisory responsibilities in accordance with organization policies and applicable laws. Responsibilities include interviewing hiring and training employees; planning assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Job Requirements:

Experience:

Required: 10 years of experience in operations management with at least 5 years in a senior leadership role involving provider contracts autoadjudication and payment integrity.

Education:

Required: Bachelors degree in Business Administration Finance Healthcare Management or a related field.

Preferred: Masters degree or relevant certifications (e.g. PMP Six Sigma).

Specialized Skills:

• Proven expertise in provider contract management claims processing and payment integrity.
• Strong analytical and problemsolving abilities with experience using data to drive decisions.
• Excellent leadership and team management skills with a track record of building and leading highperforming teams.
• Effective communication and interpersonal skills with the ability to interact with stakeholders at all levels.
• Proficiency in relevant software and tools including claims management systems and data analytics platforms.

Additional Expectations and Responsibilities

1. Strategic Leadership

• Vision and Strategy: Develop and implement longterm strategic goals and plans for their division or department aligned with the companys overall mission and objectives.
• Decision Making: Make highlevel decisions that impact the organizations direction and performance.
• Innovation: Encourage and drive innovation to keep the company competitive and adaptable to changes in the industry.

2. Operational Oversight

• Performance Management: Oversee the operational aspects of their division ensuring that processes and systems are efficient and effective.
• Budget Management: Manage and allocate budgets for their department ensuring financial targets are met and resources are used efficiently.
• Resource Allocation: Ensure the proper allocation of human financial and technological resources to achieve strategic objectives.

3. Leadership and Team Management

• Team Leadership: Lead and mentor senior managers and other key personnel fostering a productive and positive work environment.
• Talent Development: Identify and nurture talent within the organization facilitating professional development and succession planning.
• Conflict Resolution: Address and resolve conflicts within their teams and between departments to maintain a cohesive working environment.

4. External Representation

• Stakeholder Engagement: Represent the company in interactions with external stakeholders including clients partners and industry groups.
• Public Relations: Manage the organizations image and reputation through effective communication and public relations strategies.

5. Risk Management

• Risk Assessment: Identify potential risks and develop strategies to mitigate them ensuring the organizations assets and reputation are protected.
• Compliance: Ensure that their division adheres to regulatory requirements and industry standards.

6. Reporting and Communication

• Reporting: Provide regular updates and reports to the CEO and board of directors on the performance and status of their division.
• Communication: Facilitate clear and effective communication both within their department and with other parts of the organization.

7. Change Management

• Adaptability: Lead and manage organizational change initiatives ensuring smooth transitions and minimizing disruptions.
• Transformation: Drive transformation efforts to improve organizational effectiveness and efficiency.

8. Strategic Partnerships

• Partnerships: Develop and maintain strategic partnerships and alliances that are beneficial to the organizations growth and objectives.
• Negotiation: Negotiate contracts and agreements with partners vendors and other external entities.

Pay Range: $198219.00 $297329.00

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.

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