Alignment Health

Compliance

• Provide administrative and clerical support and project coordination within the quality management department
• Collect data related to quality management initiatives
• Conduct provider outreach to ensure regulatory-required compliance
• Coordinate and conduct activities with providers, external vendors, and internal departments
• Aggregate data and perform initial analysis of assigned project results
• Produce charts, graphs, and reports demonstrating results and outcomes
• Maintain up-to-date databases and tracking logs
• Request medical records for quality review activities
• Conduct phone and fax follow-up; troubleshoot, investigate, and follow up on missing information
• Collaborate with clinical staff on patient safety issues
• Perform other duties and special projects as assigned

Healthcare Quality Coordinator – Provider Outreach, Compliance

Bilingual

• Provide telephonic case management to medically complex and chronically ill Special Needs Plan members
• Conduct comprehensive health assessments and create individualized care plans
• Coordinate care with internal and external partners, including physicians and specialists
• Educate members and caregivers on disease management and preventive care
• Monitor member progress and advocate for timely, appropriate interventions
• Identify and help resolve service or access issues impacting care quality
• Conduct all communication via phone, email, and Teams
• Perform essential physical functions including talking, hearing, standing, walking, sitting, handling objects or controls, reaching, and occasionally lifting or moving up to 10 pounds

Telephonic RN Case Manager – Special Needs Plan, Bilingual Preferred

Director

• Lead the end-to-end provider enrollment function from contract execution through provider activation
• Oversee provider and entity onboarding activities for contracted providers, facilities, ancillary providers, IPAs, and delegated entities
• Establish governance for contract implementation workflows across contracting, credentialing, enrollment, and provider data teams
• Ensure provider records are accurately configured across downstream operational systems
• Develop standardized enrollment procedures, controls, and quality assurance processes
• Manage delegated credentialing roster submissions, provider loads, onboarding standards, loading protocols, and validation controls
• Partner with Delegation Oversight teams to meet regulatory, contractual, and accreditation requirements
• Monitor delegated provider load accuracy, turnaround times, and service-level agreement compliance
• Lead remediation for roster discrepancies and audit findings
• Oversee non-participating and non-contracted provider enrollment processes, policies, workflows, monitoring, and reporting
• Partner with Claims, Network Management, and Provider Data teams to support accurate claims adjudication and provider identification
• Establish provider enrollment data standards and quality controls
• Lead data validation, reconciliation, and audit activities
• Develop performance metrics and dashboards for provider onboarding, delegate load performance, inventory aging, and enrollment cycle times
• Support provider directory accuracy and provider data integrity initiatives
• Ensure compliance with CMS, NCQA, state, and accreditation requirements
• Support audits, surveys, and delegated oversight reviews
• Maintain compliance policies, procedures, and documentation
• Implement controls to mitigate operational and compliance risks
• Lead, develop, and mentor provider enrollment managers and operational teams
• Establish productivity, quality, and service performance standards
• Drive process improvement through automation, workflow optimization, and technology solutions
• Partner with executive leadership on network growth, market expansion, and strategic provider initiatives
• Manage departmental budgets, vendor relationships, and operational performance

Director, Provider Enrollment

QA Automation Engineer

• Define and maintain a multi-year AI and automation roadmap supporting Medicare Advantage priorities
• Partner with C-suite and senior leaders to identify and prioritize high-ROI AI and automation use cases
• Lead design and implementation of enterprise-grade automation solutions, including RPA, workflow orchestration, and process intelligence
• Establish standards and governance for automation development, documentation, and change management
• Own selection and adoption of AI/ML platforms, cloud services, and automation tools
• Define and enforce engineering best practices including CI/CD, MLOps, testing, observability, and documentation
• Collaborate with Product, Data Engineering, Clinical Operations, Finance, Compliance, and Security to translate requirements into technical solutions
• Track realized business value including cycle-time reduction, accuracy improvement, and cost-to-serve
• Communicate AI and automation strategy, progress, and ROI to senior executives and governance bodies
• Ensure AI and automation solutions meet CMS, HIPAA, and internal governance standards
• Implement frameworks for bias detection, model explainability, auditability, and change control
• Own the AI & Automation Engineering operating budget, including cloud spend, third-party platforms, and external partners
• Evaluate and manage vendor relationships
• Provide technical leadership, mentoring, and cross-functional direction without direct reports

Principal AI – Automation Engineer

Operations

• Identify operational inefficiencies, performance gaps, and workflow bottlenecks across the organization
• Lead current-state and future-state process redesign efforts
• Implement process improvements that reduce complexity, improve operational outcomes, and enhance member and provider experiences
• Establish standards, best practices, and continuous improvement methodologies
• Lead cross-functional initiatives supporting strategic business objectives and operational transformation
• Partner with business leaders to evaluate operating models and identify opportunities for effectiveness and scalability
• Develop implementation plans and drive execution of transformation initiatives
• Support organizational adoption of new processes and operating models
• Establish performance measures and success metrics
• Analyze operational performance data and identify improvement opportunities
• Develop reporting and dashboards showing initiative progress and business outcomes
• Quantify operational, financial, and service impacts of transformation efforts
• Build and lead a team responsible for process improvement and transformation initiatives
• Influence stakeholders across business functions and build alignment around improvement priorities
• Advise leadership on operational performance, scalability, and continuous improvement
• Mentor and develop direct reports
• Foster a collaborative, accountable, and results-oriented culture

Director, Process Improvement

• Develop and execute the organization's enterprise transformation strategy
• Lead large-scale transformation programs improving operational efficiency, member and provider experiences, and organizational growth
• Identify opportunities to improve performance, reduce costs, increase scalability, and strengthen competitive positioning
• Serve as executive sponsor for high-priority enterprise initiatives
• Lead annual and multi-year strategic planning processes
• Translate strategic goals into actionable initiatives and measurable outcomes
• Establish mechanisms to monitor and report progress against strategic objectives
• Lead enterprise capital planning and strategic investment management
• Establish governance frameworks for strategic initiatives and capital investments
• Oversee business cases, financial analyses, ROI assessments, and investment recommendations
• Develop and maintain enterprise transformation roadmaps
• Oversee strategic initiative portfolios and manage dependencies, risks, milestones, and resources
• Lead process improvement and operational excellence programs using Lean, Six Sigma, and continuous improvement methodologies
• Redesign core business processes and improve productivity and service quality
• Develop and execute Total Cost of Care strategies
• Lead organizational change efforts, stakeholder engagement, communication, and organizational readiness
• Present recommendations and progress updates to senior leadership and Board committees
• Build and lead a high-performing transformation and operational excellence team
• Mentor leaders and establish best practices in strategic planning, portfolio management, and process improvement

VP Operational Excellence

Auditor

• Conduct provider- and coder-level reviews and audits to ensure accurate risk-adjustment data submission to CMS
• Develop and maintain tracking tools for Risk Adjustment Compliance
• Review and audit outcomes and findings
• Monitor corrective action plans resulting from review or audit findings
• Monitor internal reporting for coding outliers
• Review IPA policies and procedures for compliance
• Monitor internal coding staff accuracy percentages
• Monitor coding vendor accuracy and data quality submitted to CMS
• Work with Risk Adjustment Management on data validation and RADV coding audits
• Ensure compliance with applicable federal, state, and local regulations and organizational standards
• Suggest customized Risk Adjustment education for support staff, providers, employees, vendors, and departments
• Handle protected health information in accordance with HIPAA standards
• Represent the department in RADV and other risk-adjustment audits
• Maintain professional and technical knowledge through education and professional activities

Medicare Risk Adjustment Compliance Auditor, CPC, CCS, CCS-P

Data Analyst

• Perform routine and ad-hoc analyses across operational datasets to uncover trends, variance drivers, root causes, and performance risks
• Design, build, and maintain dashboards and reporting tools
• Partner with Operations, Finance, IT, Quality, Compliance, and Product teams to investigate issues and develop data solutions
• Translate analytical findings into business implications and recommendations
• Support standardized data definitions, data quality checks, and KPI frameworks
• Serve as an analytics resource and data steward for new systems, workflows, process redesign, and operational transformations
• Develop analytical models and forecasting tools for capacity planning, performance improvement, and strategic initiative evaluation
• Identify opportunities to automate data collection, reporting, and workflow processes
• Create visual storytelling artifacts for technical and non-technical audiences
• Support regulatory, compliance, and audit-related reporting
• Perform other duties and projects as assigned
• Individual contributor role with no supervisory responsibilities

Quality Improvement Data Analyst

Clinician

• Conduct in-home assessments on Alignment members, medication review and health screenings
• Provide patient education by matching care desired with best care given
• Identify diagnoses to be assessed in care management and active medical management
• Partner and communicate with the Regional Medical Officer and other team members to develop appropriate care plans
• Coordinate care with PCPs, specialists, and ancillary providers
• Lead a broader clinical team, including nurses, health coaches, social workers, and care coordinators
• Provide care and support to Alignment Healthcare patients in their homes to help prevent unnecessary hospitalizations, health complications, and unmanaged disease progression

Advanced Practice Clinician, Care Anywhere

Data Engineer

• Design and govern data architecture across operational systems, cloud platforms, and analytics environments
• Build and maintain conceptual, logical, and physical data models supporting risk adjustment, HEDIS reporting, Star ratings, and CMS encounter data submissions
• Establish and enforce data governance frameworks covering data quality, lineage, PHI/PII classification, and audit readiness
• Integrate structured and unstructured data from claims systems, EHRs, pharmacy platforms, and third-party sources into unified data pipelines
• Define and uphold security architecture meeting HIPAA, CMS, and SOC 2 requirements
• Evaluate and recommend data platforms, cloud technologies, and vendors
• Serve as the primary technical data partner to leaders across clinical operations, population health, finance, product, and compliance
• Scope and pilot emerging capabilities including generative AI, FHIR interoperability, and real-time streaming
• Lead through technical authority and cross-functional influence without direct supervisory responsibility

Enterprise Data Architect

Customer Retention Specialist

• Serve as a subject matter expert for escalated member calls involving disenrollment risk
• Resolve escalations using knowledge of healthcare, authorizations, claims, provider network issues, processes, and protocols
• Identify process improvement opportunities within the Member Engagement department
• Meet and exceed assigned monthly goals
• Provide expert information about procedures, protocols, benefits, and services
• Conduct outbound and receive inbound calls within department goal timeframes
• Adapt communications to members' preferences, including time of day, channel, and language; use interpreter services as needed
• Collaborate with other departments, supplemental benefit vendors, and provider networks to facilitate the member experience
• Share best practices and participate in team meetings and training
• Provide outbound support for PCP/IPA terminations
• Ensure information and assistance comply with applicable federal/state laws, regulations, and health plan requirements
• Document interactions in real time and complete timely wrap-up in required systems/applications
• Accurately enter member demographics and information to support outcomes reporting and organizational data quality
• Participate in required meetings and training concerning company processes, health plan benefit packages, and CMS
• Assist with development and training of new hires, including shadowing
• Support other assigned projects and duties

Quality Retention Specialist, Chinese – Mandarin Speaker

• Manage and coordinate healthcare for members with complex and chronic care needs within scope of licensure
• Deliver care using the nursing process
• Interact with members, caregivers, and interdisciplinary team participants
• Help close care gaps and resolve barriers to improved health
• Reach out to and connect with members by telephone
• Coordinate care as a resource for members, families, and physicians
• Ensure access to appropriate care for urgent or immediate needs
• Facilitate referrals and authorizations within the benefit structure
• Complete comprehensive assessments of health status, resource utilization, treatment plans, and services
• Collaborate with members, PCPs, and care teams to implement care plans
• Interface with physicians, hospitalists, nurse practitioners, and specialists on care-management treatment plans
• Provide education and self-management support
• Assist providers with claims or service issues
• Coordinate with delegated or contracted providers, groups, and entities
• Maintain confidentiality of protected health information in compliance with law and company policy

Bilingual RN Case Manager, SNP – California RN License

Data Scientist

• Collaborate with Stars, clinical, and care management leaders to understand HOS performance drivers and translate them into analytical solutions
• Segment members by likelihood to respond to the HOS survey and predicted physical or mental health trajectory to prioritize outreach and intervention
• Build and fine-tune models predicting member-level risk of HOS composite decline
• Analyze item-level HOS survey data to identify survey questions driving measure performance
• Build pipelines tracking HOS survey administration cycles, cohorts, sampling, fielding, and response rates
• Validate case-mix adjustment logic against CMS methodology
• Model statistical significance and year-over-year variance to distinguish performance shifts from survey noise or sampling error
• Coordinate with HOS survey vendors on cohort tracking, sampling methodology, fielding timelines, and case-mix adjustment specifications
• Collaborate with engineering teams to version, test, and deploy models using Git, CI/CD pipelines, and VM environments
• Partner with clinical, care management, Compliance, and Legal teams to align outputs and interventions with CMS guidance
• Build dashboards tracking measure-level HOS performance against Star Rating cut points and prior-year trends
• Standardize definitions, documentation logic, and reporting workflows for enterprise-wide HOS analytics

Data Scientist – HOS Analytics

• Conduct Utilization Management and Case Management audits in accordance with regulatory, contractual, and industry standards
• Evaluate delegated entities’ compliance with CMS, contractual, and Alignment Healthcare UM/CM requirements
• Maintain complete, organized, and audit-ready documentation
• Execute audits using established methodologies, sampling criteria, and risk-based approaches
• Communicate audit scope, expectations, timelines, documentation needs, findings, and corrective actions to delegated provider organizations
• Present findings, explain root causes and performance gaps, and support delegates with corrective-action requirements
• Review and validate Corrective Action Plans and evidence of remediation
• Track CAP progress and complete follow-up activities through closure
• Identify high-risk areas using historical results, monitoring data, clinical trends, and operational challenges
• Recommend audit prioritization and refine audit scopes and schedules
• Escalate emerging risks, irregular findings, systemic issues, and complex CAP matters to the Manager, Audit Administration
• Prepare audit summaries, reports, dashboards, and materials for leadership, committees, regulators, and executives
• Collaborate with Delegate Performance, Clinical Operations, Quality, Compliance, and other stakeholders
• Manage multiple concurrent audits and support training, education, regulatory audit preparation, and special projects