Director, Claims Audit

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 c