Job Description

Montage Health’s application process has changed effective 12/20/2019.
If you submitted an online application prior to 12/20/2019, you will be required to recreate your profile information if you want to apply to any new positions. You will no longer have access to your previously saved profiles and applications. Current employees applying for transfer into a posted position must also create a profile.

  • Excellent Pay and Generous Benefits including a Pension and Continuing Education Reimbursement
  • Excellent Team Orientated Culture
  • Free Gym for Employees

Job Description:

Company Overview

The Aspire Health Plan (AHP) is a subsidiary of Montage Health (MH). Other subsidiaries of Montage Health include:

  • Community Hospital of the Monterey Peninsula (CHOMP) a 250 bed tertiary hospital,
  • Community Health Innovations (CHI) a accountable care services organization, and
  • Montage Medical Group, a 1204(a) multispecialty clinic.
  • Coastal Third Party Administrators (Coastal TPA), a wholly-owned subsidiary of Aspire Health Plan

Aspire introduced a new Medicare Advantage product line in 2014 to serve the needs of the Medicare eligible population in Monterey County. This population segment of our community represents one of the fastest growing segments of the county in coming years, and their demands for comprehensive health care and maintaining overall wellness are growing with their increasing numbers. By offering attractive Medicare Advantage plans, Aspire rounds out the services MH subsidiaries already provide, creating value added services for seniors to achieve the triple aim of improving care for the individual, reducing cost, and improving the health of the community. 

In addition to the at-risk Medicare Advantage line of business, Aspire Health Plan also administers health plans for self-funded employer health benefit plans in the commercial sector. These services include comprehensive medical management and health plan analytic activities typical of well managed health plans. Aspire’s proven practices provide added value for plan sponsors who recognize the importance of a holistic approach to plan management and the control of their employee health benefit expenses while ensuring access to the quality healthcare provided by their plans.

Purpose of Position

In support of the Operations Director, the Manager of Health Plan Operations will be responsible for management and oversight of Enrollment, Mailroom, Claims and Pharmacy operations for all lines of business and will assist with ensuring compliant operations. The individual will also be responsible for key operational annual projects such as Annual Plan Reporting, Operational Readiness and ad hoc audits of operational units. This position also works closely with the Compliance department to ensure that AHP operates within the policies, procedures, and regulations set forth by AHP, by insurance carrier partners, and by state and federal laws, including HIPAA and Fraud/Waste and Abuse statutes and regulations.

Responsibilities

  • Monitor and assess legislative and regulatory developments to determine organizational impact.
  • Maintain current on all regulatory requirements with all applicable state and federal rules, regulations, and laws, including CMS, PHS, IRS, HIPAA, ERISA, COBRA, ACA, and the Knox-Keene Act.
  • Monitors industry best practices and makes recommendations for organizational policy and procedure change that will result in operational compliance. 
  • Interacts effectively with various internal and external departments to provide assistance and information.
  • Efficiently and effectively documents information and activities so they can be tracked, trended and utilized for compliance verification and general process improvement.
  • Manage and oversee the federally regulated COBRA process to ensure compliance
  • Oversee the production of identification cards as required for new implementations and renewals.
  • Manage the resolution of  all eligibility issues and other insurance inquiries
  • Oversee the annual coordination of benefits (COB) and dependent verification mailing as delegated by Client(s).
  • Oversee the mailing of annual Part D Creditable Coverage and Children’s Health Insurance Reauthorization Act (CHIPRA), as delegated by Client(s).
  • Provide account management support and serve as the liaison between the delegated Pharmacy Benefits Manager and internal staff.
  • Oversee pharmacy operations for all lines of business, in coordination with the Clinical Pharmacist and the Pharmacy Services Specialist.
  • Creates reporting for executive management monthly and on an ad hoc basis.
  • Monitors and approves monthly compliance indicators in the Online Monitoring Tool (OMT) used by internal staff and First Tier Entities (FTEs).
  • Responsible for management and oversight of Annual Plan Reporting/Data Validation, in coordination with the Compliance department.
  • Responsible for management and oversight of the annual ODAG/CDAG Timeliness Monitoring Project.
  • Support oversight of operational units (enrollment, claims, mailroom, pharmacy); Plan, conduct, and coordinate operational audits.
  • Trains staff on organizational policies and ensures policies are followed at all times.
  • Represent Operations Department in meetings and oversight committees, as required.
  • Participates as part of, and in support of, a management team that works collaboratively to ensure the success of Aspire Health Plan’s goals, objectives, and strategic initiatives.
  • Manage pharmacy specialist and/or other staff on the Health Plan Operations team
  • Perform other duties as assigned.

Competencies

  • Accountability and Dependability: Assumes responsibility for accomplishing duties in an effective and timely manner.
  • Integrity:  Consistently honors commitments and takes responsibility for actions and words.  
  • Software and Computer Skills: Proficient in the use of Microsoft Office Suite, Highly skilled at using the Internet .Must learns effectively with computer-based and/or online training.
  • Flexibility:  Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.
  • Inclusiveness:  The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.

Position Requirements

  • Bachelor’s degree preferred in related field
  • 3 to 5 years’ of management  experience within the health care industry
  • Working knowledge of Medicare Advantage operations and compliance
  • Working knowledge of federal regulation specific to the administration of self-funded employer health and welfare plans, including ERISA, Department of Labor and Health and Human Services
  • Intermediate MS Office skills including Word, Excel, Outlook and PowerPoint required
  • Exceptional Alphanumeric Data Entry skills required
  • Knowledge of healthcare contracting, benefit and premium administration
  • Experience designing, conducting and monitoring audits
  • Knowledge of health plan operations and issues
  • Strong leadership and management skills
  • Excellent organizational and interpersonal skills
  • Excellent business acumen and writing skills
  • Exceptional diplomacy skills to effectively resolve issues under sometimes tense and stressful circumstances
  • Readily adaptable to the changing needs of the business; able to manage multiple priorities; tolerance for ambiguity
  • Ability to use sound judgement, identify next steps to be taken, and develop appropriate solutions.
  • Ability to collaborate with multiple parties to solve problems

Preferences

Benefits           Competitive benefit package

Salary              Commensurate with experience

Aspire Health Plan is an equal opportunity employer.

Assigned Work Hours:

Position Type:

Regular

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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