Clinical Operations Manager

Cascade Comprehensive Care Inc•Klamath Falls, OR

20d•Hybrid

About The Position

The Clinical Operations Manager oversees clinical operations, including timely, regulation-compliant medical and dental authorizations and personalized, timely, comprehensive, and cost-effective care coordination. The role oversees compliance with state and federal requirements and Medicaid plan contractual requirements related to utilization management and care coordination. The manager leads medical and dental utilization review, contract deliverables, and compliance work. The position coordinates care across settings, supports appropriate levels and quality of care, reviews complex cases and authorization requests with the Director of Clinical Operations and Chief Medical Officer, and works with local and out-of-area providers. It also identifies members with complex or high-cost care needs and oversees interventions, care planning, referrals, and transitions intended to support optimal outcomes and effective use of healthcare resources. The role collaborates with internal departments and providers, supports quality-measure improvement and process-improvement projects, and helps maintain operating instructions and procedure manuals. The position requires confidentiality and HIPAA compliance, regular and predictable attendance, teamwork, effective communication under pressure, and a willingness to take direction from a manager. This is a hybrid position. A background check and drug screen are required.

Requirements

Bachelor’s degree from a four-year college or university in a related field, plus three to five years of related experience and/or training, or an equivalent combination of education and experience.
Valid Oregon Registered Nursing (RN) license.
Certified Case Manager (CCM) certificate or equivalent required within eighteen months.
Specialized computer skills, including proficiency with database, spreadsheet, report-writing, project-management, graphics, word-processing, presentation, email, and scheduling applications.
Excellent communication skills, including presentation, persuasion, and negotiation skills.

Responsibilities

Manage medical and dental utilization review processes for members.
Lead management of contract deliverables and compliance related to utilization management and care coordination.
Apply knowledge of Medicaid benefit packages and administer those benefits.
Lead identification of members with catastrophic, complex, and chronic medical management needs and assess and deliver potential management options and alternatives.
Oversee coordination of care across care settings to support appropriate care and optimal outcomes.
Manage processing of authorization requests for dental, medical specialty and ancillary referrals, hospitalizations, durable medical equipment, skilled nursing facility placements, inpatient rehabilitation, long-term care stays, and home health services.
Oversee determinations of appropriate level and quality of care and collaborate with the team to identify alternative levels of care.
Work with the Director of Clinical Operations and Chief Medical Officer to review complex cases and authorization requests.
Ensure coordinated care planning and appropriate use of healthcare resources.
Support utilization management with local and out-of-area providers.
Ensure the utilization review team refers members to care coordination as appropriate.
Review high-cost utilization reports for individual members, including emergency department, hospital, outpatient, and readmission costs, and identify and manage interventions to reduce costs.
Facilitate timely transitions between care settings and transitions to other CCOs or plans.
Support effective care coordination to optimize outpatient care, remove discharge barriers, and help avoid lengthy hospitalizations.
Attend or ensure department representation at meetings with primary care clinics, hospitals, skilled nursing facilities, and local DHS to facilitate care coordination and access to care.
Collaborate with departments and providers to improve communication and processes related to utilization management and care coordination.
Support the Quality Department in improving Oregon Health Plan quality measures where applicable.
Participate in process improvement projects and help maintain department operating instructions and procedure manuals related to utilization management and care coordination.
Maintain confidentiality and comply with HIPAA rules and regulations.
Maintain punctual, regular, and predictable attendance and work collaboratively in a team environment.
Communicate effectively, including through presentation, persuasion, and negotiation, and remain calm and courteous under pressure.
Respectfully take direction from the manager.