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 Director of Claims Audit provides strategic leadership over the internal claims audit function, driving data-informed decision-making and process improvement across the claim’s organization. This high-impact role requires deep expertise in claims operations, CMS regulatory requirements, and audit/compliance oversight. The Director will oversee the Claims Audit team, manage key SOX and operational audit deliverables, and serve as the bridge between operations and enterprise leadership, supporting claims transformation efforts and key system initiatives to optimize processes, reduce risk, and enhance efficiency.Job Duties/Responsibilities:
Lead the design, execution, and continuous improvement of internal claims audit activities, including monitoring, tracking, root cause analysis, and issue resolution.
Ensure compliance with CMS regulations, SOX requirements, and other applicable federal and state mandates; serve as a liaison with Compliance, Legal, and Finance to maintain audit process integrity and readiness.
Oversee preparation and delivery of monthly, quarterly, and ad hoc reporting packages for senior leadership, Audit Committees, and external auditors, including internal audit control reviews and PWC discussions.
Provide data-driven insights by compiling and analyzing claims audit metrics, trends, and variance drivers; develop actionable recommendations to mitigate risks and support operational decision-making.
Partner with Claims Optimization and Operations teams to identify recurring audit issues, performance gaps, or anomalies, and translate findings into sustainable process improvements.
Collaborate cross-functionally to design and implement corrective action plans (CAPs), report cards, and long-term operational solutions that reduce audit findings and enhance efficiency.
Manage weekly audit monitoring reports, engage with BPO partners and internal teams to resolve findings, and track corrective action progress.
Contribute to enterprise-level presentations and initiatives by preparing audit-related insights, analyses, and operational performance updates.
Support other departmental or enterprise priorities as assigned, adapting to evolving business needs.
Job Requirements:
Experience:
Required:
10+ years of experience in health plan operations, claims auditing, compliance, or process optimization.
4+ years in a leadership role, managing cross-functional teams or enterprise-level initiatives.
Demonstrated expertise in CMS regulations, SOX, audit committee reporting, and internal/external audits (e.g., PWC, CMS).
Proven track record of leading initiatives that reduced manual effort, resolved high-volume claim categories, and improved operational efficiency.
Strong understanding of the claims lifecycle, audit principles, and regulatory compliance, with the ability to translate findings into actionable operational improvements.
Strategic thinker with the ability to influence and partner across multiple departments to drive change and optimize processes.
Advanced analytical and reporting skills, including experience with Excel, SQL, and data visualization tools (Power BI, Tableau, or similar).
Excellent communication and presentation skills, capable of engaging executives, auditors, and operational teams.
Demonstrated ability to lead change, prioritize competing initiatives, and operate effectively in a complex, high-visibility environment.
Education:
Bachelor’s degree required (Healthcare Administration, Business, Healthcare Management, or related field); or equivalent combination of education and experience.
Master’s degree (MBA, MHA) preferred.
Training:
• Required: None
Specialized Skills:
Required:
Advanced reporting and data analysis skills (Excel, SQL, Power BI/Tableau preferred).
Strong communication skills, with the ability to present complex data to executives and auditors.
Operational mindset with ability to identify gaps and implement sustainable, efficient solutions.
Proven change leader who can drive adoption across multiple departments.
Comfortable operating with ambiguity, tight timelines, and enterprise-level visibility.
Licensure:
• Required: None
Other:
Required: Intermediate to Advance proficiency in MS Office products – Word, Access, PowerPoint, Visio and Excel
Preferred: Proficiency in data analysis tools such as Excel or SQL; visualization experience a plus
Hands-on experience working with the claims system, Facets claims system a strong plus
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 accommodation 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 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
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 https://reportfraud.ftc.gov/#/. 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 [email protected].
Top Skills
What We Do
Alignment Healthcare is redefining the business of health care by shifting the focus from payments to people. We’ve created a new model for health care delivery that cuts costs and improves lives by unraveling the inefficiencies of the current system to drive patients, providers and payers toward a common goal of wellness. Harnessing best practices from Medicare Advantage, our innovative data-management technology allows us to commit to caring for seniors and those who need it most: the chronically ill and frail. Alignment Healthcare provides partners and patients with customized care and service where they need it and when they need it, including clinical coordination, risk management and technology facilitation. Alignment Healthcare offers health plan options through Alignment Health Plan, and also partners with select health plans to help deliver better benefits at lower costs. For more information, please visit www.alignmenthealthcare.com.
