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Senior Director, Provider Appeals

2 weeks ago

Orange, California, United States Alignment Health Full time $149,882 - $224,823

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 Senior Director, Provider Appeals leads the enterprise-wide strategy, operations, and regulatory compliance for the provider appeals function within Alignment. This role ensures timely, accurate, and compliant adjudication of provider payment disputes, coverage appeals, clinical appeals, and adminis-trative reviews in accordance with CMS regulations, state requirements, and internal policies.
This role ensures timely, accurate, and compliant resolution of provider appeal cases, while driving op-erational excellence, supporting staff development, and leading continuous improvement initiatives. The Sr. Director acts as a key liaison between cross-functional teams and driving collaboration.

Job Responsibilities:

Strategic Leadership & Governance

  • Develop and maintain the strategic roadmap for the 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.
  • Represent the organization in regulatory audits related to appeals and provider dispute resolution processes.
Operational Excellence
  • Oversee day-to-day operations and staff management of provider appeals intake, routing, clinical reviews, payment dispute resolution, escalation pathways, and final determination issuance.
  • Ensure appeals are resolved within all CMS-mandated timeframes and internal SLAs.
  • Implement standardized workflows, automation capabilities, and technology solutions to improve accuracy, reduce cycle times, and enhance provider experience.
  • Lead root-cause analysis and corrective action planning for appeal trends, denials, claims edits, and contract disputes.

Regulatory & Compliance Alignment

  • Ensure all provider 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.

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.

Cross-Functional Collaboration

  • Partner with Claims, Provider Contracting, and Network Operations to reduce preventable appeals and resolve systemic failures impacting 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 a team of intake specialists, appeal reviewers and adjudicators responsible for case documentation and decision-making.
  • Provide coaching and case-level guidance to ensure accurate and defensible determinations.
  • Set expectations for decision quality and serve as a subject matter expert for complex cases.

Supervisory Responsibilities:

  • Oversees assigned staff. Responsibilities include: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and performance management.

Job Requirements:

Experience:

Required:

  • 7+ years of appeals, utilization management, claims review, medical policy, or clinical adjudication experience.
  • 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.

Preferred:

  • Experience writing or reviewing medical necessity determinations or complex claim appeals.
  • Prior experience participating in or preparing for CMS or NCQA audits.

Education / Training:

Required:

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

Preferred:

  • Master's degree

Specialized Skills:

Required:

  • Effective written and oral communication skills
  • Data-driven with ability to interpret complex data sets and translate into actionable insights.
  • Exceptional leadership, communication, and cross-functional collaboration skills.
Pay Range: $149, $224,823.00

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.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at  If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email