Associate Vice President, Encounters

The Associate Vice President, Encounters leads Alignment Health's encounter data function and is accountable for the strategy, operating model, controls, and performance required to deliver complete, accurate, and timely Part C and Part D submissions to CMS, effective reconciliation and remediation, and reliable encounter data capture from delegated and capitated provider groups.

Reporting to the Senior Vice President, Claims & Payment Integrity, the AVP translates the broader Claims & Payment Integrity strategy into encounter-specific priorities and leads cross-functional accountability across Claims Operations, Configuration, Technology, Compliance, Finance, Network Management, and delegated oversight so systemic defects are corrected at the source rather than managed at submission.

The AVP serves as the senior functional leader for encounter data and partners closely with Risk Adjustment, which retains ownership of clinical documentation strategy. The AVP owns encounter data governance, submission performance, control effectiveness, and the identification and escalation of revenue and compliance exposure, while recommending capability, technology, and resource investments to the SVP. This builder must lead through managers and specialized teams while maintaining strong technical, regulatory, and financial acumen.

Job Duties/Responsibilities:

Build the Encounters Function

· Design and lead the Encounters operating model, including organizational structure, decision rights, governance, control standards, performance routines, and escalation protocols, in alignment with the broader Claims & Payment Integrity strategy.

· Develop and execute the approved capability roadmap for the Encounters function, recommending the appropriate mix of internal talent, technology, processes, and vendor support to improve control, scalability, and cost effectiveness.

· Establish the encounter performance and risk framework, including submission completeness and timeliness, acceptance and rejection trends, reconciliation status, control effectiveness, delegated-entity performance, and revenue or compliance exposure.

· Build and lead a high-performing organization through accountable managers and specialized teams spanning submission operations, data quality, reconciliation, analytics, and delegated-entity performance; develop leadership capability and succession depth.

Encounter Data Submission & Operations

· Provide executive oversight and functional accountability for Part C encounter submissions through EDPS, ensuring the 837 institutional and professional lifecycle, rejection remediation, resubmission processes, and supporting controls meet CMS requirements and approved performance standards.

· Establish governance and shared accountability with the pharmacy organization and PBM for Part D prescription drug event submission, reconciliation, error resolution, and timely escalation of material performance or compliance risk.

· Ensure disciplined MAO-002 and MAO-004 reconciliation through management controls that identify, prioritize, and remediate material variances between submitted, accepted, stored, and risk-adjustment-eligible data.

· Establish governance and control standards for chart review and supplemental data submissions, including adds and deletes, to ensure submissions are accurate, supported, traceable, and coordinated with Risk Adjustment and Compliance.

· Hold the organization accountable for an integrated regulatory submission calendar, operational readiness, and timely escalation of risks that could affect CMS deadlines, sweep dates, or correction windows.

Delegated & Capitated Provider Group Data

· Set the strategy, standards, and accountability model for obtaining, validating, and submitting encounter data from delegated and capitated provider groups, with clear remediation and escalation for late, incomplete, or inaccurate data.

· Establish enterprise-aligned encounter data requirements, service expectations, scorecards, and governance for delegated entities, ensuring transparent performance reporting and timely corrective action.

· Lead cross-functional escalation and remediation with Network Management, Contracting, Compliance, and delegated oversight for material or recurring delegated-entity performance failures, escalating contractual or enterprise-level matters to the SVP as appropriate.

· Ensure delegated entities receive actionable performance and root-cause insights and are held accountable for sustainable correction of data-quality issues at the source.

Data Quality & Root-Cause Remediation

· Define and govern the encounter data quality framework, including validation standards, error taxonomy, data lineage, root-cause methodology, control monitoring, and executive visibility into systemic defects and exposure.

· Establish cross-functional accountability with Claims Operations, Configuration, Technology, and Data teams to prioritize and remediate recurring defects in Facets configuration, intake, adjudication logic, and data interfaces at the source.

· Set performance expectations and management controls for rejection inventory, aging, and remediation; hold leaders accountable for sustained backlog prevention and escalate material exposure or resource constraints.

· Establish a preventive control environment that detects data-quality and compliance issues before submission and supports audit readiness, issue remediation, and continuous improvement.

Partnership with Risk Adjustment

· Serve as the executive Encounters partner to Risk Adjustment, using complete and accurate encounter data to identify revenue opportunity and exposure, prioritize remediation, and inform financial forecasts while preserving clear functional ownership.

· Ensure Risk Adjustment receives reliable, reconciled, and decision-ready encounter data and transparent reporting needed to support compliant program targeting and financial analysis.

Job Requirements:

EXPERIENCE

Required:

• 10+ years of progressive experience in Medicare Advantage encounter data, claims operations, or healthcare data operations, including 5+ years leading teams.
• Health plan (payer) experience is required, including direct ownership of encounter data submission inside a payer organization.
• Deep working knowledge of Part C EDPS submission, the 837 lifecycle, CMS response files, and error correction and resubmission.
• Experience with MAO-004 reconciliation and with identifying and closing gaps between submitted, accepted, and stored data.
• Experience collecting and remediating encounter data from delegated or capitated provider groups.
• Demonstrated results improving acceptance rates, clearing rejection backlogs, or recovering revenue tied to unsubmitted or rejected encounters.
• Executive-level communication skills, with the ability to make a technical data problem legible to executives and to providers.

Preferred:

• Experience building an encounters function, or insourcing encounter operations previously run by a vendor.
• Part D prescription drug event (PDE) submission and reconciliation experience.
• Experience with chart review and supplemental data submissions, including delete logic.
• Experience with Facets or a comparable core claims administration platform.
• Experience partnering with a Risk Adjustment organization on revenue opportunity identification.

EDUCATION

Required: Bachelor's degree in business, healthcare administration, information systems, finance, or a related field, or an equivalent combination of education and experience.

Preferred: Master's degree.

LICENSURE / CERTIFICATION

Required: None.

Preferred: None.

SPECIALIZED SKILLS

• Builder. Able to design and launch a function, including the team, processes, and tools.
• Technical mindset. Fluent with encounter data, EDI transactions, response files, and reconciliation logic; able to analyze data and direct analysts and engineers. Hands-on coding is not required.
• Operational rigor. Insists on reconciliation and closes the loop on every difference rather than accepting a tolerance.
• Financial acumen. Connects data completeness to dollars and can quantify what an open error category is costing.
• Influence. Holds delegated groups and internal partners accountable to standards while keeping the relationship productive.
• Root-cause orientation. Fixes defects at the source instead of building workarounds at the point of submission.

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 accommodations 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: $198,219.00 - $297,329.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.