Associate Vice President, Claim Payment Accuracy

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 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 Associate Vice President Claim Payment Accuracy owns the enterprise discipline for identifying prioritizing and permanently remediating issues that cause claims to pay incorrectly. This is an operational excellence and transformation role not a day-to-day claims production or quality assurance role. The AVP leads cross-functional work from signal and root cause through corrective action validation and sustained control.
The role partners across Payment Integrity Claim Audit Claim Operations Configuration Technology Data Finance Compliance Network and other claim-adjacent functions. Its north star is to reduce avoidable payment leakage and systematically decrease reliance on retrospective Payment Integrity recovery by fixing upstream process configuration data policy and technology defects.
Fraud waste and abuse activities may sit within the organization led by this role; however the AVP is accountable for the broader claim payment accuracy agenda. Success requires strong analytics disciplined problem solving executive influence and the ability to drive changes across teams without relying solely on direct authority.

Define and lead the enterprise claim payment accuracy strategy operating model governance and multiyear roadmap.

Establish a single transparent portfolio of known and emerging payment issues across prepay postpay audit operations configuration provider and FWA signals.

Create a consistent method to size prioritize and sequence issues based on financial exposure member and provider impact compliance risk recurrence and remediation complexity.

Define clear accountability decision rights escalation paths and closure criteria for cross-functional remediation work.

Build and direct an analytics-led capability that connects recovery audit adjustment denial configuration provider and operational data to identify systemic payment defects.

Translate Payment Integrity recoveries and Claim Audit findings into root-cause themes quantified exposure and actionable upstream fixes.

Distinguish isolated errors from recurring patterns and enterprise defects and focus resources on issues with the greatest preventable value.

Develop practical measurement for payment accuracy defect recurrence time to remediation prevented loss and sustained financial impact.

Partner with Data and Technology teams to improve data availability traceability and analytical tooling. Hands-on coding is not required but the AVP must be able to challenge methods interpret results and direct analysts.

Lead structured root-cause analysis across people process policy configuration data vendor and technology dimensions.

Convert findings into funded owned remediation plans with milestones dependencies controls and measurable outcomes.

Coordinate implementation across Claim Operations Configuration Product Technology Payment Integrity Claim Audit Finance Network and other impacted functions.

Validate that fixes work as intended quantify prevented value monitor recurrence and reopen issues when results are not sustained.

Ensure temporary containment is used when necessary while a durable upstream correction is designed and implemented.

Provide leadership oversight for FWA work housed within the function and ensure appropriate coordination with Compliance Legal Payment Integrity Network and Claim Operations.

Ensure substantiated FWA patterns inform preventive controls payment policy provider action and broader remediation priorities.

Maintain clear handoffs for regulatory investigative recovery and operational remediation responsibilities without duplicating Compliance accountability.

Chair or lead governance forums that review the payment accuracy portfolio remove barriers assign ownership and make prioritization decisions.

Partner with Payment Integrity to convert retrospective findings into prospective prevention and to prevent duplicate or conflicting interventions.

Partner with Claim Audit to translate audit results into enterprise learning and corrective action rather than treating findings as isolated quality events.

Partner with Claim Operations to design practical changes that improve accuracy without creating unnecessary operational burden or avoidable disruption.

Communicate exposure decisions progress realized and prevented value and unresolved risk to the SVP Claims & Payment Integrity and executive leadership.

Design the organization roles skills routines and analytical capacity required to manage the payment accuracy agenda.

Recruit develop and lead a team that may include analytics root-cause program leadership and FWA capabilities.

Create a culture of fact-based problem solving ownership urgency transparency and durable resolution.

Required

10 years of progressive experience in health plan claims payment integrity operational excellence enterprise transformation analytics audit or a related discipline including 5 years leading teams or complex cross-functional programs.

Health plan payer experience with a strong understanding of end-to-end claim payment processes and the upstream factors that affect payment accuracy.

Demonstrated success identifying systemic problems conducting or directing root-cause analysis and driving corrective action across multiple functions.

Strong analytical orientation and experience using claims financial operational or audit data to size problems prioritize work and validate outcomes.

Experience establishing governance portfolio management and executive reporting for complex remediation or transformation initiatives.

Proven ability to influence senior leaders resolve competing priorities and maintain accountability across teams without direct reporting authority.

Executive-level communication skills including the ability to simplify complex issues quantify impact recommend decisions and communicate risk.

Preferred

Medicare Advantage and CMS claim payment experience.

Experience leading an analytics payment accuracy claims transformation operational excellence or enterprise remediation function.

Working knowledge of healthcare reimbursement claim configuration payment policy provider data and core claims administration platforms.

Experience with Facets or a comparable core claims administration platform.

Familiarity with data visualization SQL statistical analysis process improvement or automation tools; direct technical execution is not required.

Required: Bachelors degree in business healthcare administration analytics finance information systems engineering or a related field or an equivalent combination of education and experience.

Preferred: Masters degree.

Required: None.

Preferred: Lean Six Sigma process improvement project or program management analytics or related certification.

Systems thinker. Connects downstream payment outcomes to upstream process policy configuration data technology and provider causes.

Analytical leader. Frames questions tests assumptions sizes exposure evaluates methods and converts data into decisions.

Operational excellence mindset. Builds repeatable mechanisms that eliminate defects at the source rather than managing recurring symptoms.

Transformation leadership. Moves complex cross-functional work from diagnosis through implementation validation and sustained adoption.

Enterprise influence. Creates alignment clarifies accountability and drives decisions across organizational boundaries.

Financial discipline. Separates identified recovered avoided and validated value and ensures benefits are credible and traceable.

Pragmatic judgment. Balances speed risk member and provider impact operational feasibility and long-term durability.

Clear communication. Presents complex claim payment issues in a concise executive-ready story with a specific decision or action.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job the employee is regularly required to talk or hear. The employee regularly is required to stand walk sit use hand to finger handle or feel objects tools or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $198219.00 - $297329.00

Pay range may be based on a number of factors including market location education responsibilities experience etc.

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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