Job Description


Monterey, CA

Full Time (Exempt)

Work Hours: Business Hours M-F 8-5

2/1/2019

ASPIRE HEALTH PLAN
 
Position:     Manager, Health Plan Operations
Location:    Monterey, CA
Reports to: Director of Health Plan Operations
Schedule:   Exempt
 
Position Summary
The Manager of Health Plan Operations will be responsible for direct management and oversight of the Appeals & Grievance Department and will assist the Director of Health Plan Operations with oversight of other operational functions. The individual will be responsible for all Annual Plan Reporting and ad hoc audits of operational units. This position also works with the Director of Compliance 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.
  • Maintaincurrentonallregulatoryrequirements 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.
  • Plans, organizes, and directs the work activity of the Appeals and Grievance team consistent with organizational policies and procedures which are compliant with state and federal guidelines.
  • Oversees research, investigation, negotiation and resolution of all types of Appeals and Grievances.
  • Identification and remediation of Appeal and Grievance trends discovered through routine audit.
  • Works with departmental business owners on process improvement to decrease  Appeal and Greivance volume.
  • Manages first tier entity responsible for A&G intake and provides guidance on complex issues.
  • 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 Officer.
  • Responsible for management and oversight of the annual ODAG/CDAG Timeliness Monitoring Project.
  • Support oversight of operational units (enrollment, claims, call center, medical management); Plan, conduct, and coordinate operational audits.
  • Trains staff on organizational policies and ensures policies are followed at all times.
  • Representat 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.
  • Performotherdutiesasassigned.
Competencies 
  • AccountabilityandDependability:Assumesresponsibilityforaccomplishingdutiesinaneffectiveandtimelymanner.
  • 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 in related field
  • 3 to 5 years’ of management  experience within the health care industry
  • Working knowledge of Medicare Advantage regulations, resources and processes
  • 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
About Aspire
Aspire Health Plan is a locally owned Medicare Advantage HMO that provides comprehensive medical coverage to seniors and other Medicare recipients in Monterey County. We’re proud to be a community-centered organization backed by Community Hospital of the Monterey Peninsula and Salinas Valley Memorial Hospital. Over 700 doctors, many other healthcare providers, and all four Monterey County hospitals are part of the Aspire Health Plan network. It’s the care you need from people you know.

Aspire Health Plan is an equal opportunity employer.

Application Instructions

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