Career Opportunities: Clinical Operations Manager (24958)

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.

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.