Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.
Job Title
Clinical Operations Manager
Department
Clinical Operations
Exemption Status
Exempt
Requisition #
24958
Direct Reports
Team Supervisors and Support Staff
Manager Title
Director, Clinical Operations
Pay & Benefits
Estimated hiring range $ 135,420 - $165,520 /year, 5% bonus target, full benefits.
www.careoregon.org/about-us/careers/benefits
Posting Notes
This is a fully remote position, but you must reside in one of the listed 9 states. The schedule is Monday - Friday, with the opportunity to move to a 4/10 schedule in the future.
Job Summary
This position is responsible for managing multiple clinical and non-clinical teams and resources. Areas of oversight include prior authorizations, referrals, concurrent review, and durable medical equipment (DME). This includes the development and implementation of program standards and procedures, monitoring program impact, and ensuring effectiveness and integrity. This position works closely with other managers across the organization to ensure collaboration, integration and support of organizational activities and goals.
Essential Responsibilities
Operational Management
Oversee the operational and clinical functions of multiple teams.
Work collaboratively with department leaders to oversee program standards and procedures and to monitor program impact and effectiveness on the health, experience, and cost of care for the membership.
Lead teams in setting and fulfilling established goals and objectives.
Develop and implement utilization programs and services to ensure the use of CareOregon resources meet medical appropriateness and least costly alternative criteria; this entails oversight of multi-million-dollar costs of services.
Ensure policies and procedures meet CareOregon/Division of Medical Assistance Program (DMAP) contracting requirements and the Centers for Medicare and Medicaid (CMS) requirements.
Ensure program compliance with DMAP, CMS, and other relevant regulatory bodies that oversee health plan operations.
Ensure integration of work between program functional areas; manage changes across teams and communications within CareOregon and between partners, providers and members.
Act as a technical and operational resource to program supervisors.
Ensure unit work is performed in coordination with other relevant CareOregon departments; service as a liaison and collaborator with multiple teams including provider customer service, claims, appeals and grievances, population health, information systems, and others.
Keep current on standards for health plan operations related to utilization and case management.
Perform on-going analysis of data and information, looking for opportunities for improvement in appropriate utilization of resources.
Frequently communicate with providers and partners to problem solve issues and improve workflows.
Monitor outlier utilization and communicate with Finance department and reinsurer to ensure compliance with contracted reporting expectations.
Collaborate with IS on system performance, improvement and function ability to maximize performance of multiple technology platforms and products, and to provide reporting to internal and external stakeholders.
Program Development, Improvement, and Evaluation
Assist in regularly developing programmatic guidelines, and ensure these guidelines are followed.
Identify opportunities for improvement and participate in their development and implementation, including process improvement initiatives.
Develop, utilize and regularly monitor measures/metrics to improve the program's effectiveness and efficiency of work processes.
Create a unit environment that encourages professionalism and teamwork and uses progressive problem solving to meet expectations.
Employee Supervision
Manage 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.
Organizational Responsibilities
Perform work in alignment with the organization's mission, vision and values.
Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
Strive to meet annual business goals in support of the organization's strategic goals.
Adhere to the organization's policies, procedures and other relevant compliance needs.
Perform other duties as needed.
Experience and/or Education
Required
Current unrestricted RN license for state of Oregon
Minimum 5 years' nursing experience, including at least 2 years in utilization management and/or case management
Preferred
Minimum 2 years' experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon's Aspiring Leaders Program
Bachelor's degree in Nursing or Masters degree in health related field
Process improvement and project management experience
Health Plan experience, including detailed knowledge of the Oregon Health Plan (OHP) benefit and the Division of Medical Assistance Programs (DMAP) and the Centers for Medicare and Medicaid Services (CMS) rules and regulations
Experience with NCQA Accreditation, certification in Utilization Management (CPUM), Health Care Management (CPHM), Managed Care Nurse (CMCN) or Case Management (CCM)
Knowledge, Skills and Abilities Required
Knowledge
Advanced knowledge of managed care concepts and principles
Advanced knowledge of health plan regulatory requirements for Medicaid and Medicare managed care plans
Advanced knowledge of basic health plan operations
Advanced knowledge of utilization management concepts, principles and practices
Advanced knowledge of care coordination and case management concepts, principles and practices
Knowledge of principles of organizational change and ability to act as a change agent
Knowledge of disease management and health promotion principles and processes
Skills and Abilities
Excellent time management and organizational skills
Excellent reading, oral and written communication skills
Excellent problem solving and decision-making skills
Excellent interpersonal skills
Ability to effectively collaborate with the department's medical directors, leadership and staff, and other stakeholders/customers
Ability to work well under pressure in a complex and rapidly changing environment
Ability to negotiate skillfully and to build consensus
Ability to manage staff, including mentoring staff growth
Ability to oversee services involving substantial costs
Ability to support and comply with organizational policies, procedures and guidelines
Ability to use basic computer programs commonly used for health plan operations
Ability to implement projects and to train staff to new processes and procedures
Ability to develop and implement procedures and program standards
Ability to manage multiple tasks, complex projects, and to delegate as deemed appropriate
Ability to work as an effective team member and leader in a complex and fast-paced environment
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, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to hear and speak clearly for at least 3-6 hours/day
Working Conditions
Work Environment(s): ? Indoor/Office ? Community ? Facilities/Security ? Outdoor Exposure
Member/Patient Facing: ? No ? Telephonic ? In Person
Hazards: May include, but not limited to, physical and ergonomic hazards.
Equipment: General office or mobile equipment
Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit or other means of transportation may be used.
Work Location: Work from home
MULTI
Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.
Veterans are strongly encouraged to apply.
We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.
Visa sponsorship is not available at this time.
