Alignment Health

Bilingual

• Reach out to members telephonically to assist with referrals, authorizations, HHC, DME needs, medication refills, make provider appointments and follow ups, etc.
• Create cases, tasks, and complete documentation in the case management module for all hospital and skilled nursing facility (SNF) discharges
• Comply and document tasks assigned by nurse
• Work as a team with the case manager to engage and manage a panel of members
• Manage new alerts and update case manager on changes in condition, admission, discharge, or new diagnosis
• Establish relationships with members, earn their trust and act as patient advocate
• Escalate concerns to nurse if members appear to be non-compliant or there appears to be a change in condition
• Assist with outreach activities to members in all levels of case management programs
• Assist with maintaining and updating members' records
• Assist with mailing or faxing correspondence to members, primary care physicians (PCP), and / or Specialists
• Request and upload medical records from PCP’s, specialists, hospitals, etc.
• Meet specific deadlines (respond to various workloads by assigning task priorities according to department policies, standards, and needs)
• Maintain confidentiality of information between and among health care professionals

Bilingual Spanish Care Coordinator, Outpatient Case Management

Compliance

• Own the analytics, reporting, and performance monitoring framework for both internal operations and delegated entities to support regulatory compliance and oversight requirements
• Serve as a hands-on contributor in developing reports, dashboards, and analytics — including writing queries, building visualizations, and synthesizing insights for performance improvement
• Lead the development and maintenance of dashboards and scorecards that measure delegate performance, contractual compliance, corrective action progress, and operational risk indicators
• Partner with Compliance, Delegation Oversight, and Operations teams to define expectations, metrics, and escalation criteria for delegate monitoring
• Conduct root cause analysis and trend evaluations on compliance issues, audit findings, or delegate performance gaps, providing data-backed recommendations for corrective action
• Prepare and validate data and reports to support CMS, state, or internal audits and readiness reviews, including universe build development and reconciliation
• Present findings and risks to leadership and cross-functional stakeholders with clear storytelling and recommended actions

Manager, Compliance – Delegate Oversight Reporting and Analytics

Manager

• Track performance to ensure alignment with the overall objectives of the health plan
• Receive ongoing reporting from clinical or RAF teams gaps
• Work with IPAs to develop, implement and monitor progress of remediation plans for performance improvement
• Serve as the IPAs’ main point of contact on day-to-day activities
• Attend external meetings with IPA leaders as required
• Document and follow up on action items from the meetings
• Participate in Joint Operating Committees (JOC) and other collaborative meetings

IPA Manager

Director

• Design and lead the enterprise care routing strategy, aligning provider selection and referral pathways with organizational goals for quality, affordability, access, and member experience.
• Define and maintain preferred network frameworks that segment providers based on performance, capacity, access, and clinical outcomes.
• Establish clear, data-driven criteria for identifying high-performing providers while ensuring adequate access for members across geographies and specialties.
• Own the development of network intelligence capabilities that integrate claims, utilization, clinical outcomes, access, and member demand data.
• Evaluate network adequacy beyond regulatory compliance measures, assessing whether the network meaningfully meets member needs related to access, capacity, timeliness, specialty coverage, and care continuity.
• Identify gaps, redundancies, or misalignments in the network that may impact care routing effectiveness or member experience.
• Provide data-driven recommendations to adjust network composition, provider mix, or geographic coverage based on performance and access insights.
• Design and embed care routing workflows within existing operational teams (e.g., UM, Care Management, Member Services, Provider Relations, Scheduling) to steer members to preferred providers while preserving access and choice.
• Build, lead, and develop a small, high-performing team focused on network intelligence, care routing execution, and network adequacy analysis.

Director, Preferred Networks – Care Routing

• Design and stand up the enterprise MSO operating model supporting direct providers, hospital groups, and PPO-aligned networks.
• Define standardized end-to-end workflows spanning onboarding, credentialing, claims, UM, quality, and performance management.
• Establish scalable governance models for varying provider relationships (direct, hospital-employed, delegated entities, PPO partners).
• Ensure operating model flexibility to accommodate market-specific needs while maintaining enterprise consistency.
• Partner with Technology and Data teams to define system requirements, reporting infrastructure, and automation to support MSO operations.
• Standardize internal workflows across UM, Claims, Network, Finance, and Clinical Operations to support multiple provider models with minimal variation.
• Lead enterprise issue intake, tracking, and resolution processes for provider operational issues across all provider types.
• Identify systemic issues impacting provider partners and drive cross-functional remediation.
• Reduce administrative friction for providers by eliminating redundant processes and manual workarounds.
• Partner with Data teams to develop standardized performance scorecards tailored to direct providers, hospital groups, and PPO-aligned providers, with consistent core metrics and model-specific views.
• Establish enterprise performance review and engagement cadences that markets can execute locally.
• Enable targeted steerage strategies aligned to preferred, high-performing providers across all provider types.
• Build a consistent provider experience framework across direct providers, hospital groups, and PPO networks.
• Implement enterprise provider education programs tailored to different provider models while maintaining consistent standards.
• Own provider feedback loops, including surveys and NPS, and translate insights into operational and experience improvements.
• Align enterprise and market communications to ensure clear, coordinated messaging to providers across all arrangements.

Senior Director, Provider Success

• Provide enterprise leadership for internal clinical quality oversight, performance monitoring, and workforce training across a national Medicare Advantage health plan
• Build and lead an internal clinical quality audit function focused on evaluating employee performance, clinical decision-making, documentation, and adherence to policies and workflows
• Establish audit methodologies, sampling approaches, scoring criteria, and reporting standards to assess quality and consistency of internal clinical work
• Conduct routine and targeted audits across clinical and operational roles (e.g., care management, utilization management, clinical reviews)
• Identify performance gaps, patterns of non-adherence, and operational risks; perform root cause analyses to distinguish training, process, and system issues
• Develop, implement, and oversee corrective action plans (CAPs) tied to audit findings, including retraining, workflow changes, and performance monitoring
• Track corrective action effectiveness and ensure sustained improvement through follow-up audits and trend analysis
• Own the enterprise clinical quality training strategy aligned to audit findings, regulatory requirements, and operational priorities
• Design and implement role-based, competency-driven training programs that translate clinical standards and policies into practical, repeatable execution
• Lead development of standardized curricula, onboarding programs, refresher training, job aids, and performance support tools
• Ensure training programs are embedded into day-to-day operations and reinforced through leadership coaching and performance management
• Partner with Learning & Development to leverage adult learning principles, delivery modalities, and learning management systems
• Integrate audit results and training outcomes into a continuous feedback loop to drive performance improvement
• Collaborate with Clinical Operations, Compliance, Human Resources, and Analytics teams to align performance monitoring, training, and corrective action efforts
• Present audit findings, performance trends, and improvement plans to senior leadership
• Define success metrics for audit performance, training effectiveness, and corrective action outcomes
• Develop dashboards and reporting to monitor trends, risks, and improvement over time
• Lead, mentor, and develop a team of quality auditors, trainers, and clinical subject matter experts

Senior Director, Clinical Training & Quality

• Reaches out to members telephonically to assist with referrals, authorizations, HHC, DME needs, medication refills, make provider appointments and follow ups, etc.
• Creates cases, tasks, and completes assessments in Case Management module for all Hospital and SNF discharges.
• Works as a team with the Case Manager to engage and manage a panel of SNP members.
• Establishes relationships with members, earns their trust and acts as patient advocate.

Care Coordinator, Bilingual Spanish

• Supervise, review, and participate in the development and implementation of the annual SG&A plan (budget), forecast, multi-year financial plan and analysis of major projects and investments.
• Lead the annual SG&A budgeting and forecasting processes and coordinate with Finance and Operational leadership on Capital Expenditure budgeting.
• Analyze various strategic projects and incorporate into the financial plan.
• Provides monthly/quarterly analyses on various issues, e.g. cash flow analysis, capital spending performance, etc.
• Develop financial projections using driver-based forecasting and rolling forecast methodologies.
• Partner with operations leaders to quantify the financial impact of performance improvement initiatives.
• Manage and mentor a team of financial analysts, fostering a culture of continuous improvement and professional development.

Director of FPA

• Responsible for the health care management and coordination of care for members with complex and chronic care needs
• Assures compliance with SNP program requirements as outlined in the Model of Care
• Monitors activities to support the timeliness of Health Risk Assessment completion
• Monitors and reports program performance, including vendor performance monitoring
• Oversee audits, regulatory compliance, and quality assurance activities
• Provide coaching, performance reviews, and staff development to support team success

Manager, Case Management, RN

• Owns and leads the full software application release lifecycle, including planning, scheduling, coordination, deployment, and post‑release validation across multiple engineering teams.
• Drives release readiness and risk mitigation, facilitating testing sign‑off, approvals, rollback planning, and go/no‑go decisions.
• Collaborates with DevOps to enhance and maintain CI/CD pipelines and deployment automation to support secure, reliable, and scalable application deployments.
• Ensures compliance with HIPAA, SOC2, and internal control requirements by maintaining accurate release documentation and audit artifacts, and providing required materials to Compliance teams.
• Serves as the primary liaison for application release communication, delivering clear, timely updates on plans, risks, and outcomes to both technical and non‑technical stakeholders.
• Monitors deployment health and leads issue resolution during and after releases, partnering with engineering teams to support incident management and root‑cause analysis.
• Continuously improves application release processes, tooling, and metrics, identifying opportunities to increase reliability and reduce deployment risk.

Software Release Manager

Customer Support

• Responsible for leading and developing a team of Customer Experience Specialists
• Deliver compassionate, seamless, and fully accountable service to our members
• Champion a culture built on caring connections, true ownership of member issues, and first-call resolution
• Ensure Specialists advocate for members, navigate systems effectively, and resolve root causes
• Monitor and improve first call resolution performance and follow-through behaviors
• Conduct live call monitoring, coaching, and documented feedback sessions focused on empathy, ownership, and resolution
• Directly supervise a team of Customer Experience Specialists

Customer Experience Supervisor

Auditor

• Conduct audits in accordance with regulatory, contractual, and industry standards
• Execute detailed claims audits using established methodologies, sampling frameworks, and documentation standards to ensure accuracy, consistency, and regulatory readiness
• Communicate audit scope, expectations, and timelines clearly to delegated provider organizations throughout the audit lifecycle
• Review and validate Corrective Action Plans (CAPs) submitted by delegated entities to ensure remediation fully addresses identified deficiencies

Auditor, Delegate Claims

Business Development Rep

• Develops and executes growth strategies to expand market presence
• Leads and manages strategic provider agreements
• Designs innovative contracting models
• Analyzes and shapes reimbursement strategies
• Collaborates with teams to achieve targeted growth

VP, Business Development

IT Support

• Design Audit and Monitoring Strategy.
• Develop an annual, risk based‑ audit and monitoring strategy for all delegated provider functions.
• Integrate inputs from subject matter experts, operational leaders, and monitoring data to ensure audit plans are targeted, evidence based, and aligned with organizational priorities.
• Implement Audit and Monitoring Activities.
• Lead, train, and align auditors and specialists to ensure consistent application of audit methodologies, tools, and strategies.
• Cross-Functional Collaboration & Integration.
• Partner with Delegate Performance, clinical operations, quality, compliance and other internal teams to align audit expectations with operational goals and performance initiatives.
• Reporting, Insights & Continuous Improvement.
• Develop clear, concise, and executive‑ready audit reports, dashboards, and summaries that highlight key risks, patterns, and performance trends across delegated entities.

Senior Manager, Audit Administration

• Conduct credentialing audits in accordance with regulatory, contractual, and industry standards
• Execute delegated credentialing audits using established methodologies, sampling criteria, and documentation standards to ensure accuracy, consistency, and regulatory readiness.
• Evaluate delegated entities’ compliance with CMS, DMHC, NCQA, federal/state credentialing requirements, and Alignment’s contractual standards.
• Maintain organized, complete, and audit-ready documentation to support regulatory reviews, accreditation audits, and internal oversight.
• Ensure all audit activities align with the enterprise audit strategy set by the Manager, Audit Administration.
• Engage delegated provider organizations to correct deficiencies and improve performance
• Communicate audit scope, expectations, and timelines clearly to delegated provider organizations throughout the audit lifecycle.
• Provide delegates with clear explanations of audit findings, including root causes, compliance gaps, and potential operational impacts.
• Support delegated entities in understanding credentialing requirements and expectations for corrective actions.
• Promote productive and professional working relationships to foster transparency, collaboration, and continuous improvement.
• Perform risk assessment and prioritize audits
• Assist in identifying high-risk focus areas by reviewing prior audit results, monitoring data, and operational issues related to credentialing performance.
• Recommend audit prioritization based on risk severity, regulatory sensitivity, and emerging compliance trends.
• Provide input to refine audit scopes and schedules in alignment with the Manager’s risk-based audit and monitoring strategy.
• Escalate emerging risks or irregular credentialing issues to the Manager, Audit Administration for strategic review and inclusion in future audit planning.
• Validate corrective actions for credentialing compliance
• Review and validate Corrective Action Plans (CAPs) submitted by delegated entities, ensuring remediation fully addresses identified credentialing deficiencies.
• Assess evidence such as updated credentialing files, process changes, workflow revisions, and policy updates to confirm compliance with regulatory and contractual standards.
• Track CAP progress and ensure follow-up activities are completed and documented according to departmental requirements.
• Escalate irregular, incomplete, or stalled CAPs to the Manager, Audit Administration to support timely issue resolution.
• Report credentialing audit findings to facilitate organizational awareness
• Prepare clear, concise, and well-structured audit summaries highlighting key risks, deficiencies, and improvement opportunities across delegated credentialing practices.
• Contribute to department-standard reporting tools, dashboards, and audit documentation used for leadership and cross-functional communication.
• Partner with Delegate Performance, Clinical Operations, Quality, Compliance, and other internal teams to ensure findings are understood and actionable.
• Support preparation of materials for internal committees, regulatory bodies, and enterprise risk-management forums.
• Manage multiple credentialing audits simultaneously, ensuring adherence to timelines, scope, and quality standards.
• Monitor credentialing-related data to identify emerging trends, potential non-compliance, and areas requiring targeted review.
• Contribute subject-matter insights during training or education sessions for delegated entities to reinforce credentialing expectations and reduce recurring deficiencies.
• Support compilation of documentation and evidence for CMS, NCQA, or other regulatory audits.
• Perform additional responsibilities and projects as assigned.