Alignment Health

Data Engineer

• Design and develop an ingestion process for big data processing
• Translate business requirements into specifications for the data ingestion process
• Understand and deliver data solutions leading to end-to-end delivery
• Develop and implement data pipelines to support organizational initiatives
• Build and maintain ETL (Extract, Transform, Load) or ELT (Extract, Load, Transform) pipelines to move data from various sources
• Ensure data accuracy, consistency, and compliance with policies and regulations
• Collaborate with data scientists, analysts, and other stakeholders to meet data needs
• Optimize data systems for efficiency, scalability, and performance
• Create functional and technical design documents and maintain documentation for data processes

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
• Other duties as assigned by case manager (CM) supervisor, manager or director of care management.

Bilingual Care Coordinator, Outpatient Case Management

Manager

• Design end-to-end clinical interventions addressing quality, utilization, and population health priorities.
• Develop detailed current-state and future-state workflow documentation for internal and vendor-supported interventions.
• Partner with IT, product, analytics, and data teams to translate clinical workflows into technical and functional requirements.
• Support evaluation of clinical intervention vendors by assessing clinical appropriateness and evidence base.
• Lead change management efforts for new and updated clinical interventions.

Senior Manager, Clinical Interventions

• Conduct virtual, telephonic, and in-home assessments to evaluate members’ physical, mental, and social needs
• Create individualized care plans that address social determinants of health, barriers to care, and wellness goals
• Provide supportive counseling, care navigation, and referrals to community, and behavioral health resources
• Coordinate Medicaid benefits for members
• Promote Advance Care Planning and end-of-life care discussions
• Document all interventions with timeliness and accuracy
• Partner closely with RN Case Managers and the full Interdisciplinary Care Team (ICT)
• Act as a liaison between members, families, providers, and community agencies
• Support members during major transitions, including hospital discharges, home health referrals, and hospice

Bilingual Social Worker – Case Management, Special Needs Plan

Bilingual Social Worker – Case Management, Special Needs Plan, SNP

• Coordinates care by serving as a resource for the member, their family, and their physician.
• Ensures access to appropriate care for members with urgent or immediate needs facilitating referrals/authorizations within the benefit structure as appropriate.
• Completes comprehensive assessments within their scope of practice that includes assessing the member's current health status, resource utilization, past and present treatment plan, and services.
• Collaborates with the member, the PCP, and other members of the care team to implement a plan of care.
• Maintains confidentiality of all PHI in compliance with state and federal law.

RN Case Manager, SNP (Bilingual Preferred)

IT Support

• Audit Utilization Management (UM) Processes
• Review and assess all aspects of the UM lifecycle, including intake, authorization creation, clinical decision making, correspondence, documentation, timeliness, and audit-readiness
• Conduct audits of organization determinations and reviews for accuracy, quality, completeness, and timely decision-making
• Monitor and audit workflows for intake and authorization activities
• Identify systemic issues that may affect UM compliance or audit readiness and recommend corrective actions
• Compile audit findings into detailed reports and provide actionable recommendations for improving processes
• Maintain clear and accurate records of audit results
• Ensure all audits align with internal and external compliance requirements

Clinical Audit Support Specialist

• Supervise Pharmacy Technician Leads and pharmacy technicians to ensure timely and accurate completion of work supporting pharmacy operations
• Monitor team performance and provide coaching, feedback, and development opportunities
• Conduct performance evaluations and support corrective action processes as needed
• Translate strategic goals into actionable workflows for the technician team
• Foster a culture of accountability and continuous learning through coaching, mentoring, and performance feedback
• Collaborate with the Sr. Manager, Pharmacy Technicians to implement workflow improvements and operational policies
• Ensure compliance with departmental procedures and regulatory requirements
• Support audit readiness and ensure technician documentation meets internal standards
• Assist in resolving issues related to claims processing, member/provider correspondence, and PBM interactions
• Work cross-functionally to enhance workflows and improve pharmacy quality outcomes, Star performance, and member satisfaction

Manager, Pharmacy Technicians

• 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

• 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.