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 Associate Vice President, Payment Integrity will be responsible for overseeing all aspects of the payment integrity functions, ensuring the accurate and efficient processing of claims, and protecting the financial integrity of the organization. This role will lead a cross-functional team to manage key areas such as pre-payment editing, subrogation, Medicare Secondary Payer (MSP), credit balance & overpayment resolution, data mining, chart reviews, and compliance with SOX (Sarbanes-Oxley) requirements. This individual will drive initiatives to improve payment accuracy, prevent overpayments, and minimize financial risk, while ensuring adherence to regulatory guidelines and corporate policies. Additionally, this role will oversee both internal and vendor performance to achieve key cost containment objectives and lead the creation and ongoing management of the organization’s Payment Policy Committee.

Responsibilities:

1. Pre-Payment Editing & Claims Audit:

o Lead and oversee pre-payment claim edits to prevent overpayments, fraud, and compliance issues.

o Develop and implement strategies for identifying incorrect claims prior to payment, working closely with IT and analytics teams to enhance system capabilities.

o Ensure that audits comply with all relevant internal, regulatory, and compliance standards, especially in high-risk areas such as coding and billing errors.

2. Subrogation & Medicare Secondary Payer (MSP) Compliance:

o Oversee and ensure the successful execution of subrogation efforts, identifying and recovering overpayments when applicable.

o Manage MSP compliance to ensure the organization adheres to all federal and state guidelines related to secondary payer obligations, maximizing recoveries and minimizing risk.

3. Credit Balance and Collections Management:

o Direct and manage the credit balance resolution process to identify overpayments and recover funds in a timely manner.

o Ensure compliance with state and federal regulations regarding credit balance handling and reporting.

4. Data Mining & Analytics:

o Utilize advanced data mining and analytics tools to identify trends in claims payment issues, potential overpayments, and underpayments.

o Work with the analytics team to develop predictive models for identifying claims at risk of overpayment.

o Leverage data insights to drive decision-making and continuous improvement across the payment integrity process.

5. Chart Reviews & Medical Record Audits:

o Supervise chart reviews and medical record audits to validate the appropriateness of payments, ensuring they are substantiated by medical necessity and supporting documentation.

o Partner with medical professionals and internal auditors to review complex cases and address discrepancies.

6. SOX-Compliant Claims Audit & Financial Testing:

o Lead all Sarbanes-Oxley (SOX) compliant audits related to payment integrity, ensuring that processes and controls are in place to meet financial reporting and regulatory requirements.

o Oversee financial testing related to claims payments, ensuring that payment integrity is embedded within the broader financial controls framework.

o Collaborate with internal and external auditors to address any findings and ensure corrective actions are implemented.

o Oversee a team of claims auditors to ensure that claims payment accuracy is in alignment with SOX controls and financial integrity standards.

o Continuously evaluate and refine audit processes to ensure accurate payments and compliance with SOX controls, helping to mitigate risks and enhance transparency.

7. Vendor & Internal Performance Management for Cost Containment:

o Oversee both internal teams and third-party vendors to ensure performance meets established goals for payment integrity, cost containment, and efficiency.

o Monitor vendor performance against agreed-upon service level agreements (SLAs) and cost-saving targets, holding vendors accountable for meeting performance and cost objectives.

o Evaluate internal processes and vendor partnerships to identify opportunities for cost containment, cost-effective process improvements, and operational efficiencies.

o Implement strategies to optimize the cost-effectiveness of payment integrity activities, balancing operational effectiveness with financial savings.

8. Creation & Leadership of Payment Policy Committee:

o Create and lead the organizations Payment Policy Committee, ensuring alignment of policies with corporate objectives, regulatory requirements, and industry best practices.

o Work with cross-functional stakeholders, including compliance, finance, legal, and clinical teams, to establish, review, and update payment policies and guidelines.

o Ensure the committee drives the development and continuous review of policies related to payment integrity, including pre-payment edits, billing practices, claims adjudication, and payment accuracy.

o Champion the integration of new regulatory requirements and emerging industry trends into the organizations payment policies.

o Act as a subject matter expert and provide strategic direction for the organization on complex payment policy issues.

9. Leadership & Team Management:

o Manage a high-performing team of payment integrity professionals, including claims auditors, providing leadership, coaching, and development opportunities.

o Foster a culture of collaboration and continuous improvement, ensuring the team is aligned with the company’s goals and objectives.

10. Cross-Functional Collaboration:

· Work closely with other departments, including Finance, Compliance, Legal, IT, and Operations, to ensure payment integrity initiatives are aligned with overall organizational goals.

· Ensure effective communication with senior leadership on the status of payment integrity activities, including issues, trends, and outcomes.

11. Process Improvement & Innovation:

· Continuously evaluate and improve payment integrity processes to reduce operational costs, increase recoveries, and mitigate risk.

· Drive the adoption of new technologies and processes that enhance the payment integrity function, including automation, machine learning, and artificial intelligence.

12. Regulatory Compliance & Risk Management:

o Ensure payment integrity operations comply with all applicable federal and state regulations, including HIPAA, CMS, and payer-specific requirements.

o Proactively manage risks associated with claims payments, ensuring that all compliance gaps are addressed and mitigated.

Job Requirements:

Experience

Required:

o At least 10 years of experience in healthcare payment integrity, audit, or related fields with at least 5 years in a leadership role.

o Management of pre-payment editing, claims auditing, subrogation, credit balance management, and SOX compliance.

o Oversight of vendor performance, with a focus on managing relationships and ensuring cost-effective service delivery.

o Creating and leading cross-functional committees or teams, particularly related to policy development and governance.

o Strong experience with data analytics, reporting tools, and financial testing processes.

o Proven track record of and developing large teams and managing cross-functional projects.

Education

Required: Bachelor’s degree in Healthcare Administration, Business Administration, Finance, or related field

Preferred: Master’s degree

Specialized Skills

o Strong analytical, strategic thinking, and problem-solving skills.

o Excellent communication and interpersonal skills, with the ability to interact with senior leadership and cross-functional teams.

o In-depth knowledge of Medicare Secondary Payer (MSP), federal and state regulations, and payment integrity industry standards.

o Proficiency in payment integrity and claims management software, including data mining and analytics tools.

o Deep understanding of SOX compliance and audit requirements in healthcare settings.

o Proven ability to manage vendor relationships and oversee third-party performance to meet cost containment objectives.

o Expertise in developing, implementing, and leading policy committees or governance bodies.

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 20 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $172,364.00 - $258,547.00

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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