Montage Health

• Coordinate with various business teams, subject matter experts, or external entities to gather requirements and translate them into coherent Business Intelligence (BI) reports, and dashboards in Tableau, PowerBI, SSRS • Create data models, ERD and data flow diagrams as needed • Build functional data marts for in-depth analytics by stakeholders • Perform data analysis and ad-hoc queries to support business decision-making • Implement best practices to ensure data quality and data integrity • Maintain and extend Epic Caboodle platform and develop custom Caboodle data modeling components • Understand complex logic and solve data issues by coming up with sound technical solutions • Support implementation of enterprise data standards and master data management standards • Assist with data governance initiatives in the areas of data quality, data security, metadata management, and MDM • Actively contribute to all aspects of the data project lifecycle including request intake and acknowledgment, project estimation, time-tracking, and prioritization of tasks • Assist with identification, development and validation of data sources • Contribute to the department’s short-term and long-term strategic plan • Make appropriate recommendations on management of data extraction, and analysis • Maintain knowledge of the current regulations and technologies related to data management • Be an exemplary team player with excellent collaboration skills • Exhibit outstanding customer service skills with stakeholders • Perform other duties as required or assigned

Role Description The Director of Health Plan Quality is responsible for enterprise leadership of three core performance pillars: STAR Ratings, Member Experience (CAHPS & Engagement), and Risk Adjustment (RAF). This role drives an integrated strategy across these domains to optimize clinical quality, member outcomes, and financial performance for Medicare Advantage and Commercial populations. In addition, the Director provides the clinical oversight of Appeals and Grievances, ensuring a seamless and member-centric resolution process that directly enhances member experience and satisfaction. Responsibilities - STAR Ratings Leadership - Lead enterprise STAR strategy to achieve and sustain 4+ STAR ratings. - Oversee HEDIS, HOS, and administrative measure performance. - Drive cross-functional initiatives to close care gaps and improve clinical outcomes. - Align pharmacy, care management, population health, and network strategies to maximize STAR performance. - Build relationships across health systems and local providers to maximize participation and engagement in these efforts. - Member Experience & CAHPS Leadership - Share in the development of CAHPS strategy and overall member experience performance. - In conjunction with marketing and customer service teams, drive improvements across access, communication, care coordination, and member satisfaction. - Utilize member feedback, grievances, and appeals data to inform experience transformation. - Integrate health equity and culturally competent outreach strategies. - Risk Adjustment (RAF) Clinical Leadership - Serve as executive owner of RAF clinical strategy and performance, with support from Finance and Analytics to align risk adjustment, quality, and finance to optimize health plan outcomes. - Drive provider documentation accuracy and HCC capture initiatives. - Oversee prospective and retrospective programs (pre-visit planning, chart reviews, in-home assessments). - In conjunction with the Compliance department, ensure RADV audit readiness and regulatory compliance. - Monitor RAF trends and implement targeted improvement strategies. - Appeals & Grievances (A&G) Clinical Oversight - In conjunction with the Operations team, provide clinical oversight of Appeals and Grievances processes for Medicare and Employer populations. - Partner with Customer Service, Utilization Management, and Compliance to ensure a seamless and member-centric resolution experience. - Analyze A&G data, root causes, and trends to identify systemic issues and drive enterprise-wide quality improvement. - Integrate clinical A&G insights into CAHPS and member experience strategies to improve satisfaction and reduce repeat complaints. - With the Customer Service team, drive initiatives to improve first-call resolution and enhance communication with members. - Quality Improvement & Integration - With partners across all Aspire departments, integrate STAR, CAHPS, RAF, and clinical A&G into a unified enterprise performance framework. - Establish KPIs, dashboards, and executive reporting across all domains. - Drive a culture of continuous improvement and accountability. - Align initiatives with population health and value-based care strategies. - Regulatory Compliance & Accreditation - For Quality-related components, ensure compliance with CMS, ERISA, and California regulatory requirements. - With UM counterpart, plan and prepare for QI/UMC meetings (quarterly). - Participate in NCQA accreditation and audit readiness when applicable. - With the support of Aspire’s BI department, share required data submissions (for HEDIS, STAR, risk adjustment, A&G reporting). - When applicable, monitor and implement regulatory changes across all performance areas. - Provider Engagement & Performance - Partner with providers to improve STAR, CAHPS, RAF, and clinical A&G outcomes. - Develop value-based incentive programs tied to quality, experience, and documentation. - Deliver actionable provider performance reporting and education. - Leadership & Team Management - Manage budgets, vendors, and strategic partnerships. - Use advanced analytics to identify opportunities across STAR, CAHPS, RAF, and A&G and build workplans in those areas to support process improvement. - Drive cross-functional alignment across clinical, operational, and administrative teams. Qualifications - Expertise in CMS STAR methodology, CAHPS, RAF/HCC models. - Strong understanding of member experience drivers and complaint resolution processes. - Proven ability to drive enterprise performance improvement. - Strong background in value-based care and population health. - Excellent leadership and stakeholder management skills. - Data-driven decision-making expertise. Requirements - 4+ years in health plan quality leadership. - 5+ years in senior leadership roles. - Minimum of 3 years of clinical experience. - Deep experience across STAR ratings and CAHPS (required). Education - Bachelor’s degree required; Master’s preferred (MSN, MPH, MHA, MBA). License/Certifications - Active, unrestricted Registered Nurse (RN) license in any US state is required. CA RN license preferred. - Certified Professional in Healthcare Quality (CPHQ) preferred. - Certified Risk Adjustment Coder (CRC) or equivalent preferred. - Lean / Six Sigma preferred. Salary $180,000 - $210,000 (depending on experience) Assigned Work Hours Full time (remote/hybrid/onsite) Position Type Regular

• Supervising and overseeing the customer service department. • Monitoring and auditing the work performed by customer service. • Ensuring that calls are handled according to the CMS required service level. • Assisting with the screening and hiring of customer service employees. • Conducting regular coaching, mentoring and training sessions. • Supervising customer service representatives and ensuring compliance with company guidelines. • Interacting with customers via telephone, email, or in person to provide support and information.

Role Description The Clinical Pharmacist Utilization Management serves a critical role across utilization management, quality improvement, and regulatory compliance for Medicare Advantage and commercial pharmacy benefits. This position is responsible for making accurate, evidence-based coverage determinations and appeal decisions, supporting pharmacy quality initiatives tied to CMS Star Ratings, and ensuring compliance with CMS regulations. The pharmacist functions in a highly cross-functional capacity, partnering with operations, quality, compliance, vendors, providers, and customer service teams to improve medication access, safety, adherence, and member experience across all lines of business. Essential Duties and Responsibilities - Perform Part B and Part D coverage determinations and appeals in accordance with CMS regulations, plan benefits, and evidence-based clinical guidelines. - Conduct clinical drug utilization reviews and appropriately apply formularies and preferred drug lists. - Manage pharmacy quality programs impacting CMS Star Ratings, medication adherence, and Medication Therapy Management (MTM). - Provide medication therapy management (MTM) services, including outreach to members, providers, and pharmacies. - Support CMS audits, regulatory reporting, grievances, and PBM formulary compliance activities. - Manage pharmacy quality vendors, including MTM and medication adherence programs. - Assist in the preparation of materials or activities related to the Pharmacy and Therapeutics (P&T) and Utilization Management subcommittee. - Conduct telephonic member outreach to answer member questions, resolve member issues and close care gaps. - Complete interventions to improve biosimilar conversions across all lines of business. Qualifications - Pharm.D. or RPh from an accredited School of Pharmacy. - Active, unrestricted pharmacist license in California. - Medicare Advantage Part B and Part D utilization management experience preferred. - Strong analytical, organizational, and written/verbal communication skills. Requirements - Full-time (Exempt) - Regular position Benefits - Salary Range: $129,000 – $169,000 per year. Actual compensation varies by location, experience, education, and skill level. Company Description Equal Opportunity Employer

• Perform duties reviewing coverage for medications under the pharmacy and medical benefits for all lines of business necessary. • Conduct, research, and resolve any inquiries, problems, or issues in a timely manner. • Supervise and direct the support services needed for pharmacy services across all lines of business. • Continuously look for ways to improve processes and contribute to corporate and department objectives by processing all requests in a prompt, professional and courteous manner. • Input, review and decision Medicare Part B requests for J codes, Q codes, and other medical benefits drugs/supplies. • Monitor prior authorization system to ensure turnaround times are met and contact providers for additional information to facilitate coverage determination reviews. • Communicate prior authorization criteria, pharmacy benefit coverage, and formulary alternatives to physicians, physician's office staff, medical management staff and/or pharmacists. • Notify physicians, providers, and members of coverage determination request decisions. • Assist in maintaining policies & procedures, including editing, proofreading. • Support member and provider calls regarding authorization, benefit inquiries, and resolution of pharmacy-related member questions.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Under the leadership of the Office Manager, the Referral Coordinator is responsible for managing and maintaining accurate and timely documentation within the Electronic Medical Record (EMR) system. This role includes: - Monitoring the “To Be Indexed” folder - Processing urgent referrals - Ensuring all electronic documents are properly filed - Serving as a liaison with the external medical records processing company - Handling in-office medical records requests, including obtaining necessary release forms - Scanning and filing patient correspondence - Managing incoming faxes and mail - Routing documents to the appropriate staff or provider - Assisting physicians with medical correspondence - Supporting patients with record-related inquiries - Participating in staff training as needed The ideal candidate will demonstrate strong organizational skills, attention to detail, and a commitment to maintaining confidentiality and professionalism in a fast-paced, team-oriented environment. Qualifications - Experience with medical terminology (e.g., CPT and ICD 10 codes) - Understanding of medical insurance process preferred - Experience with Electronic Medical Record (EMR) systems and Microsoft applications preferred Requirements - High school diploma or general education degree (GED) - Two-year college degree and one-year office or related experience and/or training; or equivalent combination of education and experience Benefits - Hourly Evening Shift Differential: $3.00 - Hourly Night Shift Differential: $3.00 Company Description Equal Opportunity Employer

Welcome to Montage Health’s application process! Job Description: As a Utilization Management Nurse at Aspire Health Plan, you will make sure our health services are administered efficiently and effectively. You will assess and interpret member needs and identify solutions that will help our members live healthier lives. The central goal of this position is to provide operational support and clinical expertise in the areas of health care services, member benefits and clinical operations for all AHP members to improve member and provider satisfaction as well as quality of care and health outcomes. The Utilization Review Nurse will: · Determine the appropriateness of inpatient and outpatient services following the evaluation of medical guidelines and benefit determinations. · Identify and report any quality of care concerns that occur while members are in acute care and/or SNF facilities. · Support AHP's compliance to regulatory and accreditation requirements for both state and federal agencies. · Support quality audits, chart audits, and reviews of medical records as needed for either complex high-cost cases or cases with quality of care concerns. · Coordinate case management on complex cases that require additional clinical management support. · Participate in Clinical Rounds with the Chief Medical Officer. Responsibilities · Conducts initial review of prior authorization or pre-certification requests for determination of coverage for members covered by sponsored health benefit plans. · Makes determinations based on the medical necessity of plan-covered services based on internal policies reviewed and approved by the Medical Director of the plan. Where appropriate, involve the Medical Director if a partial or fully adverse medical necessity determination is expected based on the initial review. · Works collaboratively with the Director of UM to achieve all daily/weekly and monthly targets. · Participates in and supports all medical management initiatives including, but not limited to ER visits, re-admissions, OOA utilization, and identification of potentially high-cost cases. · Collaborates with care managers on care transitions for patients with an emphasis on high-risk patients at risk for readmission, as needed 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 learn 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. Position Requirements · Active unrestricted RN license required in the State of California · Working knowledge of Milliman Care Guidelines (MCG) · 3-5 years experience working in a managed care environment. · Pre-authorization and Concurrent review experience · Utilization Management experience · Support business hours of 8 AM to 5 PM, Monday-Friday PST · Strong computer skills Salary: $134,784.00 Aspire Health is an equal opportunity employer. *All Telecommuters will be required to adhere to Aspire Health Plan’s Telecommuter policy Assigned Work Hours: Full time (exempt); 100% remote Position Type: Regular