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About The Position

Requirements

• Minimum 2 years’ experience in practice management of primary or specialty care and/or Health Plan Operations that includes utilization review activity
• Knowledge of utilization management practice principles and industry standard criteria
• Knowledge of Oregon Health Plan (OHP) benefit package including rules and regulations that pertain to health plan operations
• Knowledge of Oregon Medical Assistance Program (MAP)
• Knowledge of the Centers for Medicare and Medicaid Services (CMS) rules and regulations, including Medicare A and B benefits and regulations governing Medicare Advantage plans
• Knowledge of principles of managed care and utilization management
• Knowledge of ICD-9, CPT, HCPCS coding
• Ability to work with the department, stakeholders or customers to effectively resolve issues
• Ability to use critical thinking skills in problem solving
• Ability to manage multiple tasks and to remain flexible in a dynamic work environment
• Ability to function autonomously and to effectively set priorities
• Ability to present a positive and professional image
• Ability to develop and implement processes and procedures
• Ability to provide effective leadership and supervision to groups of people
• Ability to read, write and verbally communicate effectively
• Excellent customer service skills
• Ability to use basic word processing, spreadsheet and programs and the ability to learn more complex programs
• Ability to work effectively with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, hear, speak clearly and perform repetitive finger and wrist movement for at least 6 hours/day

Nice To Haves

• Minimum 1 year experience in a supervisory or lead position or completion of CareOregon’s Aspiring Leaders Program; lead roles preferably include regular assistance to a manager or supervisor in staff hiring, coaching, performance evaluation, and other supervisory tasks
• Utilization management experience

Responsibilities

• Identify opportunities to improve the program’s effectiveness and efficiency of work processes.
• Implement, monitor and evaluate approved program changes.
• Keep abreast of Oregon Health Plan (OHP), Medical Assistance Program (MAP), and Medicare rules and regulations; inform manager, staff and other stakeholders of changes that impact decisions and practice.
• Ensure that services requests and authorizations are processed according to the (OHP) rules and regulations, Medicare regulations, and National and Local Coverage Determinations.
• Develop process documentation and training materials as needed.
• Provide orientation to new employees or provide oversight to staff who will provide the orientation.
• Provide on-going training to address programmatic and staff needs in all areas of utilization management functions.
• Make recommendations regarding the use of technologies that may enhance departmental performance and serve as a departmental resource for the implementation of any such technology.
• Keep current on system process and issues, including QNXT functions and SharePoint, including upgrades and upgrade testing.
• Act as a resource for staff and Medical Directors.
• Work with identified CareOregon staff and departments to find opportunities to support financial impact initiatives.
• Work collaboratively with other CareOregon departments.
• Ensure that CareOregon authorization decisions are based on coverage rules.
• Remain informed about current processes and tasks performed by prior authorization, referral, appeal, claim review, and concurrent review staff.
• Stay current with work processes by providing periodic coverage for staff assignments.
• Work with staff to determine coverage in the event of unplanned absences.
• Cover an assignment when necessary.
• Supervise team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
• Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
• Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
• Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
• Train, supervise, motivate, and coach employees; provide support toward employee development.
• Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.
• Ensure team adheres to department and organizational standards, policies, and procedures.
• Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
• Perform supervisory tasks in collaboration with Human Resources as needed.

Benefits

• competitive pay
• bonus opportunity
• medical, dental, vision, life, AD&D, and disability insurance
• health savings account
• flexible spending account(s)
• lifestyle spending account
• employee assistance program
• wellness program
• discounts
• multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)
• strong retirement plan with employer contributions
• PTO
• Paid State Sick Time
• paid holidays
• volunteer time
• jury duty
• bereavement leave