VP, Provider and Member Appeals & Grievances

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 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 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. 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 Di-rector, 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 avoid-able appeals and grievances at scale. Job Responsibilities: Strategic Leadership & Governance 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 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. Operational Excellence 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 Drives teams to identify process improvements with goal to reduce non-contracted provider and member escalations Regulatory & Compliance Alignment 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. Quality Assurance & Decision Consistency 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 efficiently managed to ensure timely actions and resolution Cross-Functional Collaboration 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 Team Leadership Lead and develop a multi-level leadership team including Directors, Senior Managers, and Managers responsible for the day-to-day operati