CareOregon

Manager

• Responsible for developing, implementing, and continuously improving enterprise-wide payment integrity and claims programs and strategies
• Overseeing monitoring, analysis, and reporting of claims activity (e.g., trends, outliers, high-cost claims)
• Managing development and maintenance of tracking mechanisms, dashboards, and documentation related to audits, findings, and overpayment recoveries
• Ensure accurate invoicing and reconciliation for programs and vendors; oversee processing of recoupments and refunds
• Identifying root causes of overpayments, track trends, and drive corrective actions with accountable owners
• Building business cases and ROI models to expand initiatives, resources, and technology enabling sustainable savings and improved accuracy
• Establish governance, KPIs, and reporting cadence for program performance, savings, recoveries, and risk mitigation
• Leading a portfolio of coding audits, ensuring accurate capture of diagnosis and procedure codes in claims and chart review data
• Developing and delivering training and education for providers and internal stakeholders

Payment Integrity Coding Manager

Data Engineer

• Perform Data Warehouse Architecture at an intermediate level
• Design and develop data models and ETL specifications
• Conduct data analysis and recommend solutions
• Participate in data warehouse and dashboard architecture planning
• Propose requirements, standards, and best practices for data modeling and ETL
• Conduct product and vendor research and present recommendations

IS Data Warehouse Architect II

Data Scientist

• Develop research methods and data analysis plans related to healthcare utilization, cost trends, financial forecasting, member, and provider experience.
• Expertly use appropriate software tools to retrieve, edit and tabulate data from various databases and files.
• Conduct descriptive, prescriptive, predictive analyses.
• Summarize complex data for leadership in the appropriate form (e.g., statistical summaries, narratives, charts, tables, graphs, etc.) to convey meaning, significance, and actionable information.
• Contribute/Lead in the research and development of models, algorithms, and analysis tools to mature the use and creation of self-service data products at CareOregon.
• Develop visual reporting (e.g., dashboards, scorecards, etc.) using data visualization tools such as Tableau when appropriate.
• Develop appropriate subject matter, domain expertise and serve as an expert resource.
• Collaborate with other subject matter experts to identify opportunities for building repeatable data products.
• Collaborate with business teams to understand business needs and to illicit and document requirements for analytics, algorithms, models, etc.
• Develop reporting tools to comply with regulatory reporting requirements.
• Review and assess completeness, validity, and reliability of internal data used for analysis and reporting.
• Create and maintain technical documentation such as data dictionaries, business glossaries, metric definitions, and other data resources.
• Thoroughly document models, algorithms, data products, processes and any analysis, reports developed.
• Contribute to, and actively participate in, community of practice to improve the skills and capabilities of other analysts at CareOregon.
• Assist with, prepare, and/or deliver presentations to community groups, regulatory agencies, leadership, and other teams as needed.

Data Science Analyst II

Analyst

• Perform ongoing synthesis and analysis of health care quality metric performance and other key performance indicators
• Conduct intermediate to advanced analysis of key health-related metrics and program data to identify trends, forecast performance, and calculate performance targets
• Develop dashboards and visual assessments of health care quality metric performance and key performance indicators using claims, administrative, and/or program data
• Provide data and analysis to leaders to inform strategic recommendations on health care quality
• Present data in an effective and understandable way and assist others in understanding how data can inform improvement
• Provide guidance or expertise to other analysts within I&E

Quality Improvement Analyst II

• The Payment Integrity Coding Manager is responsible for developing, implementing, and continuously improving enterprise-wide payment integrity and claims programs and strategies to ensure that CareOregon’s claims editing, coding compliance, provider education, audit and recovery, and quality assurance, align with organizational goals and compliance with American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and state regulatory requirements.
• Oversee monitoring, analysis, and reporting of claims activity (e.g., trends, outliers, high-cost claims, line-of-business segmentation).
• Manage development and maintenance of tracking mechanisms, dashboards, and documentation related to audits, findings, and overpayment recoveries.
• Ensure accurate invoicing and reconciliation for programs and vendors; oversee processing of recoupments and refunds.
• Identify root causes of overpayments, track trends, and drive corrective actions with accountable owners.
• Define and execute the enterprise payment integrity and coding audit strategy; align program goals with CareOregon’s mission, vision, values, and strategic plan.
• Lead a portfolio of coding audits (prospective and retrospective), ensuring accurate capture of diagnosis and procedure codes in claims and chart review data.
• Serve as subject matter expert for ICD-10-CM/PCS, CPT/HCPCS, and associated coding conventions; actively maintain and enforce AMA/CMS guidelines.

Financial Planning and Analysis

• Identify opportunities for process improvements and efficiency enhancements across Finance teams.
• Track current finance capabilities and skill gaps.
• Contribute to process designs that enhance productivity and accuracy and reduce redundancy.
• Ensure compliance with regulatory requirements and incorporate industry best practices.
• Collaborate with senior leadership to define and prioritize transformation projects and initiatives.
• Monitor and report on the progress of transformation projects and initiatives.
• Conduct complex reviews and assessments to information transformation portfolio decisions.
• Map capability development opportunities and highlights areas of interest (people, process, and technology).
• Participate in evaluation of new technologies and tools to support finance transformation.
• Lead the implementation of financial technology, software, and automation solutions.
• Escalate project concerns through appropriate channels.
• Create training materials and trains finance teams on new technologies to ensure successful adoption.
• Provide support to adjacent teams throughout transformation efforts.

Senior Finance Transformation Analyst

Actuary

• Manage the actuarial and financial components of value-based payment (VBP) activity and provider network reimbursement models
• Provide input in the development of VBP and other reimbursement models
• Operationalize reporting and settlement calculations, analyze performance, and communicate results and findings
• Collaborate with internal leaders to develop and maintain quality incentive payment strategies and risk models
• Advise leadership on improving CareOregon’s strategic and financial positioning
• Act as a subject matter expert on value-based payment models
• Ensure monthly and quarterly reporting is produced in accordance with contractual terms
• Analyze performance and identify opportunities to reduce costs and improve quality
• Lead the development, communication, and oversight of team and individual goals

Actuarial Services Manager

Translator

• Translate member materials from English to Spanish using computer-aided translation (CAT) software
• Adjust translation as needed to convey the style, tone, and intent of the text
• Ensure that translations properly convey meaning and adhere to reading level requirements
• Ensure translated materials are consistent with brand and style guidelines
• Provide proofreading and editing as needed to support the quality and accuracy of translated documents
• Collaborate with copywriters, graphic designers, project managers, and reviewers
• Request clarification if there is any ambiguity in the source text
• Balance time-sensitive deadline submissions with longer-term project deadlines

Spanish Translator

Medical Director

• develop, implement and execute effective programs in all areas of integration and behavioral health
• work with colleagues to develop, implement and manage clinical and wellness programs to address the needs of members
• collaboration with diverse multi-disciplinary teams
• implement, direct and oversee utilization, case, disease, and/or quality management programs
• develop and implement programs for educating participating physicians regarding quality management and utilization management issues

Payment Integrity Coding Manager

IS Data Warehouse Architect II

Data Science Analyst II

Quality Improvement Analyst II

Payment Integrity Coding Manager

Senior Finance Transformation Analyst

Actuarial Services Manager

Spanish Translator

Associate Medical Director – Behavioral Health