Qureos Mentor

Alignment Healthcare

<div>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 Sr. AI Scientist combines deep analytical expertise with advanced software engineering skills to architect and deliver high-impact AI/ML solutions on our proprietary clinical intelligence platform. This role owns complex, ambiguous problems from discovery to production deployment, drive technical excellence across the team, and mentor data scientists while partnering with engineering, product, and clinical leaders to deliver measurable outcomes for Medicare Advantage members.
Job Duties/Responsibilities<ul><li>
Architect end-to-end AI/ML solutions for complex healthcare challenges (35%): Design and deliver production-grade machine learning systems for high-stakes applications including risk stratification, clinical decision support, autonomous chart review, and fraud detection. Define technical approach, model selection, and system architecture for multi-model systems and real-time decision engines that process millions of healthcare transactions.</li><li>
Own the full ML lifecycle from experimentation to production (25%): Build reliable, scalable AI services including experimentation, validation, deployment, monitoring, drift detection, and continuous improvement. Establish instrumentation, observability, alerting, and feedback loops to ensure model performance and reliability in production environments.</li><li>
Drive technical excellence and innovation (15%): Research and apply state-of-the-art methods in deep learning, NLP/LLMs, computer vision, and causal inference to healthcare problems. Champion engineering best practices including code quality, testing, documentation, reusability, and maintainability across the data science organization.</li><li>
Partner strategically with cross-functional leaders (15%): Collaborate with Product, Clinical, Operations, and Compliance teams to identify high-value AI opportunities aligned with business strategy. Translate complex technical concepts into clear business narratives for executive audiences and influence product roadmap and technology decisions.</li><li>
Provide technical mentorship and raise the bar (10%): Guide data scientists through code reviews, architectural discussions, and pair programming. Share knowledge through internal presentations and documentation. Support hiring by conducting technical interviews and modeling best practices in analytical rigor and problem-solving.</li></ul><div></div>
Job Requirements
Experience
Required:<ul><li>
5-8 years delivering production-grade data science or ML solutions with demonstrated business impact</li><li>
Proven track record architecting complex ML systems from research to production deployment</li><li>
Deep expertise in multiple ML domains and strong software engineering fundamentals</li><li>
Experience leading technical projects and mentoring data scientists</li></ul>
Preferred:<ul><li>
Healthcare domain expertise, particularly Medicare Advantage, risk adjustment, or claims analytics</li><li>
Experience with production document understanding systems (OCR, NER, entity extraction, LLM pipelines)</li><li>
Published research, open-source contributions, or patents in ML/AI</li><li>
Track record of translating research innovations into production systems</li></ul><div></div>
Education
Required: PhD in Computer Science, Machine Learning, Statistics, or related field<div></div>
Training
Required: 
Continuous learning in ML/AI advancements, healthcare analytics, and software engineering practices
Preferred: 
Training or certification in MLOps, cloud platforms (Azure, AWS, GCP), or healthcare regulations (HIPAA, CMS)<div></div>
Specialized Skills
Required:<ul><li>
Expert-level proficiency in Data Science methods, workflows, and best practices</li><li>
Advanced Machine Learning including ensemble methods, deep learning, NLP, LLMs, and computer vision</li><li>
Strong Statistical Analysis and experimental design capabilities</li><li>
Expert programming: Python, Java, SQL, or PySpark with an emphasis on production-grade, maintainable code.</li><li>
Advanced SQL and experience with high-volume, high-dimensional healthcare data</li><li>
Proficiency with Databricks (Spark, Delta Lake), MLflow, Unity Catalog, and cloud platforms</li><li>
Experience with Git workflows, CI/CD pipelines, Docker, and modern MLOps practices</li><li>
Deep understanding of healthcare data (claims, clinical, member) and Medicare Advantage operations</li><li>
Exceptional communication skills: ability to translate technical complexity into business value for diverse stakeholders</li><li>
Strong data visualization and storytelling capabilities with proven ability to influence technical decisions</li></ul>
Preferred:<ul><li>
Experience with NoSQL databases, performance optimization, and distributed computing</li><li>
Real-time ML inference and streaming architectures</li><li>
Contributions to internal ML platforms, frameworks, or open-source projects</li><li>
Experience presenting at technical conferences or publishing research</li></ul>
This position is fully remote and open to candidates based in the United States<div></div>
Licensure
Required: None 
Preferred: Industry certifications in ML, cloud platforms, or healthcare analytics<div></div>
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.
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. 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: $172,364.00 - $258,547.00
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.<ul><li>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&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

Sr. AI & Data Scientist

<div>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.
This a hybrid position in Orange, California. 
 
The MRA Program Coordinator is responsible for supporting the Risk Adjustment team with all programs, including audits and managing all electronic medical record inventory and requests for the Risk Adjustment programs.
Job Duties/Responsibilities:<ul><li>
Provide technical and / or operational support for MRA programs</li><li>
Assist with provider outreach</li><li>
Manage inventory of all electronic PDF medical records on file in the department and ensure they are indexed appropriately for easy retrieval.</li><li>
Maintain tracking logs, detailed project schedules and assist with administrative tasks for the MRA team.</li><li>
Report on the status of programs on a regular basis</li><li>
Log all current and incoming medical records with relevant demographic information</li><li>
Request medical records on behalf of department staff from providers for data collection and quality audit purposes. Track all medical record requests and perform appropriate follow-up as needed.</li><li>
Communicate effectively with external provider office staff, maintaining professionalism and a positive attitude.</li><li>
Successfully navigate the computer to access various programs and EMR&rsquo;s (Athena), respond to e-mail requests via Microsoft Outlook, reformat medical record files on Adobe Acrobat, access electronic faxes, and navigate Windows File Explorer to manage the inventory of medical records on file.</li></ul>
Job Requirements:
Experience:
Required: Experience performing data entry
Preferred:<ul><li>
1+ year of project management experience</li><li>
1+ year of healthcare/ Medicare experience</li></ul>
Education:
Required:<ul><li>
High School Diploma or GED</li><li>
Valid driver&rsquo;s license</li></ul>
Specialized Skills:
Required:<ul><li>
Proficiency in Microsoft Office, especially Microsoft Excel</li><li>
Ability to communicate positively, professionally and effectively with others and collaborate with others.</li><li>
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with management, employees and vendors</li><li>
Mathematical Skills: Ability to perform mathematical calculations</li><li>
Reasoning Skills: Ability to prioritize multiple tasks, identify problems, collect data, establish facts.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li></ul>
Other:
Required: Ability to come into the Orange Corporate Office a couple of times a week or as needed
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: $48,373.00 - $72,559.00
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.<ul><li>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&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

MRA Program Coordinator - Hybrid in Orange, CA.

<div>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.
This is a field-remote position in Bakersfield or Tulare, Kern or Kings Counties in California. 
 
The Community Outreach Representative is responsible for generating local community brand awareness of the health plan with accountabilities in driving leads and sales (direct or indirect) through grass roots efforts. Acts as the face of Alignment Health Plan in their assigned market or geography.
Job Duties/Responsibilities:
Meets or exceeds weekly and monthly qualified lead goals. Helps local market achieve monthly sales goals; works with direct sales teams in lead development and public facing presentations (advertised or non-advertised) Cultivates new and maintains existing relationships with key senior and community influencers that culminate into lead generating events/activities and increase of name awareness for Alignment and its products. Sets-up and attends monthly events and activities through in-person visits, via telephone contact and through email, sources, plans. Events and activities include health fairs, presentations and or seminars at senior centers, food banks, churches, senior living facilities, various community organizations etc. Distributes approved marketing and event materials. Works with Corporate Marketing and Compliance Departments in the approval, development, and production of advertising materials and or invitations for events. Locates, plans, sets-up, attends and presents at Quarterly New Member Orientations and year-round Education events (as needed in a non-virtual event) in the local community. Educates the community on Alignment and its benefits, services and contracted providers and medical groups IPAs available to prospects. Promotes and increases name awareness and brand identity for Alignment and its products. Provides monthly calendar of their planned activities and ensures that all scheduled events filed Maintains weekly summary of activity and submits report on a weekly basis. Performs special projects as assigned to help drive leads for the company. Conducts and leads advertised sales mtgs in their territory. Calls on local Doctor offices to educate on the Alignment products and distribute flyers to generate referrals. 
Job Requirements:
Experience:<ul><li>Required: Minimum two (2) years of experience in grass roots marketing efforts generating leads at local in-person community events. Two years&rsquo; customer service experience.</li><li>Preferred: 5+ years&rsquo; experience in Healthcare. Healthcare marketing experience. Related experience in the Medicare and Medi-Cal Managed Care industry.</li></ul> 
Education:<ul><li>Required: High School Diploma or GED. Bachelor's degree or four (4) years additional experience in lieu of education.</li><li>Preferred: MBA</li></ul> 
Training:<ul><li>Required:</li><li>Preferred:</li></ul> 
Specialized Skills:<ul><li>Required:</li></ul><ul><li>
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.</li><li>
Computer Skills: Proficient user in MS office suite (Word, Excel and PowerPoint).</li><li>
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;</li><li>
Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly</li><li>
Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>
Report Analysis Skills: Comprehend and analyze statistical reports.</li></ul> 
Licensure:<ul><li>Required: Valid State driver&rsquo;s license, car insurance, and registration</li><li>Required: State Insurance license OR become licensed within 6 months of hire date</li></ul> 
Other:<ul><li>Required:</li></ul><ul><li>
80% or more travel by car routinely required (In assigned market).</li><li>
Travel by plane required as needed.</li><li>
Maintenance of reliable means of transportation and</li><li>
Extended works hours, as needed.</li><li>
Fully Vaccinated</li><li>
Remote work on approval.</li></ul> 
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: $53,210.00 - $79,815.00
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.<ul><li>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&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

Community Outreach Representative - Field Remote in Bakersfield, CA

<div>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.
This is a field-remote position in Charlotte, NC. 
 
The Broker Account Manager is responsible for the sales and growth of the broker channel and reports to the Vice President of Sales. The Broker Account Manager oversees all channel activity including sales production, recruitment, training and sales strategy to grow the channel while maintaining a favorable acquisition cost for the company.
GENERAL DUTIES/RESPONSIBILITIES (MAY INCLUDE BUT ARE NOT LIMITED TO): 
In overseeing the broker channel, the Broker Manager will: 
1. Increases sales and meet or exceed sales expectations through existing active relationships. 
2. Builds new selling relationships in existing markets and expansion markets to grow the broker sales channel. 
3. Manages provider relationships and assign agents to partner with Medical Groups/IPA&rsquo;s for growth. 
4. Oversees agent sales and product training including webinars for new agents, lock-in refresher trainings, and Open Enrollment recertification training. 
5. Assists with broker support channels including customer service calls and email inquiries. 
6. Oversees interactions with external agents including commissions, discrepancies, enrollment kit fulfillment, certification and contracting/appointment requirements. 
7. Ensures CMS compliance with all sales, enrollment processes and events. 
8. Oversees compliance at all times to include secret shopping and ride-alongs 
9. Provides fair and objective documentation on corrective action plans and/or performance appraisals as directed by company policies and procedures. 
10. Provides effective and objective communication to keep managing relationships apprised of any updates and/or changes within department, CMS guidelines, company policies and procedures while keeping strong morale intact. 
11. Attends all mandatory management administrative, educational and/or training courses. 
12. Other duties as assigned 
Job Requirements:
Experience:<ul><li>Required: Minimum of 2 years of general sales / marketing strategy experience.</li><li>Preferred: Medicare knowledge and/or health insurance background preferred.</li></ul>
Education:<ul><li>Required: High School Diploma or GED. Bachelor's degree or four years additional experience in lieu of education.</li><li>Preferred: MBA</li></ul>
Training:<ul><li>Required:</li><li>Preferred:</li></ul>
Specialized Skills:<ul><li>Required:</li></ul><ul><li>
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;</li><li>
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.</li><li>
Strong knowledge and understanding of the CMS Marketing Guidelines</li><li>
Must have reliable means of transportation to get to all sales activities and appointments.</li><li>
Extremely organized, detail driven and a self-starter.</li><li>
An innovator and effective leader with the ability to motivate direct team, community affiliates and provider relationships.</li><li>
Excellent public speaking and presentation skills.</li><li>
Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly</li><li>
Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>
Report Analysis Skills: Comprehend and analyze statistical reports.</li></ul>
Licensure:<ul><li>Required: None</li><li>Preferred: Current and active life insurance license within respective selling state</li></ul>
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.
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. 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.<div></div>
Pay Range: $49,486.00 - $74,228.00
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.<ul><li>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&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

Broker Account Manager - Field Remote - Charlotte, NC

<div>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.
This is a field-remote position in Bakersfield or Tulare, Kern or Kings Counties in California. 
 
The Broker Account Manager is responsible for the sales and growth of the broker channel and reports to the Vice President of Sales. The Broker Account Manager oversees all channel activity including sales production, recruitment, training and sales strategy to grow the channel while maintaining a favorable acquisition cost for the company.
GENERAL DUTIES/RESPONSIBILITIES (MAY INCLUDE BUT ARE NOT LIMITED TO): 
In overseeing the broker channel, the Broker Manager will: 
1. Increases sales and meet or exceed sales expectations through existing active relationships. 
2. Builds new selling relationships in existing markets and expansion markets to grow the broker sales channel. 
3. Manages provider relationships and assign agents to partner with Medical Groups/IPA&rsquo;s for growth. 
4. Oversees agent sales and product training including webinars for new agents, lock-in refresher trainings, and Open Enrollment recertification training. 
5. Assists with broker support channels including customer service calls and email inquiries. 
6. Oversees interactions with external agents including commissions, discrepancies, enrollment kit fulfillment, certification and contracting/appointment requirements. 
7. Ensures CMS compliance with all sales, enrollment processes and events. 
8. Oversees compliance at all times to include secret shopping and ride-alongs 
9. Provides fair and objective documentation on corrective action plans and/or performance appraisals as directed by company policies and procedures. 
10. Provides effective and objective communication to keep managing relationships apprised of any updates and/or changes within department, CMS guidelines, company policies and procedures while keeping strong morale intact. 
11. Attends all mandatory management administrative, educational and/or training courses. 
12. Other duties as assigned 
Job Requirements:
Experience:<ul><li>Required: Minimum of 2 years of general sales / marketing strategy experience.</li><li>Preferred: Medicare knowledge and/or health insurance background preferred.</li></ul>
Education:<ul><li>Required: High School Diploma or GED. Bachelor's degree or four years additional experience in lieu of education.</li><li>Preferred: MBA</li></ul>
Training:<ul><li>Required:</li><li>Preferred:</li></ul>
Specialized Skills:<ul><li>Required:</li></ul><ul><li>
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;</li><li>
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.</li><li>
Strong knowledge and understanding of the CMS Marketing Guidelines</li><li>
Must have reliable means of transportation to get to all sales activities and appointments.</li><li>
Extremely organized, detail driven and a self-starter.</li><li>
An innovator and effective leader with the ability to motivate direct team, community affiliates and provider relationships.</li><li>
Excellent public speaking and presentation skills.</li><li>
Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly</li><li>
Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>
Report Analysis Skills: Comprehend and analyze statistical reports.</li></ul>
Licensure:<ul><li>Required: None</li><li>Preferred: Current and active life insurance license within respective selling state</li></ul>
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.
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. 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.<div></div>
Pay Range: $53,210.00 - $79,815.00
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.<ul><li>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&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

Broker Account Manager - Field Remote - Bakersfield, CA

<div>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.
This position is remote in Orange, CA. 
 
The Appeals &amp; Grievance Coordinator is responsible for the day-to-day functions of the tracking and trending of all grievances, appeals, and complaints received within the Member Services Department. Acts as the primary investigator and contact person for member and provider grievances and appeals.
GENERAL DUTIES/RESPONSIBILITIES : 
1. Acknowledges the receipt of all grievance/appeals, and CTM (Complaint Tracking Module). 
2. Gathers pertinent and relevant information from the member and/or provider regarding the grievance/appeal, determines the appropriate resolution of the grievance/appeal per standard policies and procedures; and notifies the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue. 
3. Composes written correspondence to members in accordance to plan policy and CMS Guidelines. 
4. Conducts non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal. 
5. Thoroughly documents all action taken on behalf of the member or provider to resolve the grievance/appeal. 
6. Ensures that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy. 
7. Prepares case files for Medical Director Review and external (including IRE) review of grievances/appeals as appropriate. 
8. Prepares clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors). 
9. Maintains accurate and timely documentation, including complete files of all grievances/appeals. Prepares monthly and quarterly reports as requested. 
10. Identifies training opportunities and potential system and process improvements relating to grievance/appeal data. 
11. Participates in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements as well as participate in periodic CMS Audit preparations and regulator meetings/interviews. 
12. Other duties as assigned.
Job Requirements:
Experience:<ul><li>Required: Two years&rsquo; experience in data entry and general office background.</li></ul>
Three years of customer service experience. Minimum 1 year Member Services or similar experience.<ul><li>Preferred: 2 years healthcare or insurance experience in a senior setting.</li></ul>
Education:<ul><li>Required: High School Diploma or GED.</li><li>Preferred: Associate degree (A.A.) degree.</li></ul>
Training:<ul><li>Required:</li><li>Preferred:</li></ul>
Specialized Skills:<ul><li>Required:</li></ul><ul><li>
Knowledge of MediCal and Medicare Managed Care Plans.</li><li>
Ability to Keyboard/Type 40+ words per minute and use the 10-key by touch.</li><li>
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.</li><li>
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;</li><li>
Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.</li><li>
Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10&rsquo;s and 100&rsquo;s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.</li><li>
Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>Preferred: Bi-lingual (English/Spanish)</li></ul>
Licensure:<ul><li>Required: None</li></ul>
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.
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 sit; use hands to finger, handle, or feel and talk or hear.
2 The employee is frequently required to walk; stand; reach with hands and arms.
3 The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
4 The employee must occasionally lift and/or move up to 20 pounds.
5 Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Pay Range: $44,790.00 - $67,185.00
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.<ul><li>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&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

Appeals & Grievances Coordinator - Remote - Orange, CA

<div>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.
Alignment Health is seeking a remote Utilization Management (UM) Nurse &ndash; Pre-Service (LVN or RN, active California license required) to join our growing UM team. 
 
In this role, you&rsquo;ll review prior authorization requests for medical necessity across inpatient and outpatient services, applying CMS guidelines and Milliman Care Guidelines (MCG) to support timely, accurate determinations. You&rsquo;ll partner closely with providers and medical directors to ensure members receive high-quality, cost-effective care. 
 
This is a fast-paced, production-driven role ideal for nurses with recent pre-service UM experience in a managed care setting who are comfortable managing multiple cases, meeting turnaround time expectations, and collaborating cross-functionally in a fully remote environment. 
 
Schedule:
 
<ul><li>Monday &ndash; Friday, 8:00 AM &ndash; 5:00 PM Pacific Time (must be able to consistently work these hours)</li><li>Candidates must reside within Pacific, Mountain, or Central time zones to align with business hours.</li><li>Weekend rotation: approximately 1 weekend day every 5&ndash;6 weeks (4&ndash;8 hour shift between 8:00 AM &ndash; 5:00 PM Pacific Time)</li></ul>
General Duties / Responsibilities: 
1. Review pre-certification requests for medical necessity and refer to medical director any referral that requires additional expertise. 
2. Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilize Milliman Care Guidelines (MCG) to assist in determinations of referrals. 
3. Maintain goals for established turn-around time (TAT) for referral processing. 
4. Initiate single service agreements (SSA) when services required are not available in network. 
5. Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible. 
6. Verify eligibility and / or benefit coverage for requested services. 
7. Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests. 
8. Contact requesting provider and request medical records, orders, and / or necessary documentation in order to process related pre-service requests / authorizations when necessary. 
9. Review referral denials for appropriate guidelines and language. 
10. Assist medical directors in reviewing and responding to appeals and Grievances 
11. Contact members and maintain documentation of call for expedited requests. 
12. Other duties as assigned.
Job Requirements:
Experience:
Required:<ul><li>
Minimum (3) years' nursing experience in clinical setting.</li><li>
Minimum (1) year experience UM experience with pre-service.</li><li>
Minimum (1) year experience with managed care (Medicaid and / or Medicare).</li><li>
Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)</li><li>
Minimum (1) year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred</li><li>
Minimum (1) Experience with the application of clinical criteria, specifically Milliman Care Guidelines (MCG)</li></ul>
Education:<ul><li>Required: High School Diploma or GED.</li><li>Preferred: Associates or Bachelor's degree in Nursing</li></ul>
Licensure:
Required:<ul><li>
Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact)</li><li>
Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company.</li></ul>
Preferred:<ul><li>
CPHQ or ABQAURP, or Six Sigma certification</li><li>
Medical Terminology Certificate.</li></ul>
Training:<ul><li>Required: None</li><li>Preferred: Medical Terminology. Six Sigma</li></ul>
Specialized Skills:
Required:<ul><li>
Knowledge of ICD-10, CPT codes, managed care plans, medical terminology and referral system (Access Express / Portal / N-coder).</li><li>
Knowledgeable with CMS (Chapter 13) guidelines and regulations.</li><li>
Computer Skills: Word, Excel, Microsoft Outlook</li><li>
Language Skills: Effective written and verbal communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees and vendors.</li><li>
Mathematical Skills: Able to perform mathematical calculations and calculate simple statistics correctly.</li><li>
Reasoning Skills: Able to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>
Report Analysis Skills: Comprehend and analyze statistical reports.</li></ul>
Preferred:<ul><li>
Bilingual English and Spanish</li><li>
Transplant knowledge a plus</li></ul>
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: $77,905.00 - $116,858.00
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.<ul><li>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&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule)

Join Alignment Healthcare and explore 24   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.