CareOregon

Data Engineer

• Perform data warehouse architecture or enterprise data architecture at a senior level
• Focus on design and development of data models and ETL specifications
• Analyze data sources and partner with leaders across the organization
• Recommend long-term data architecture goals and planning
• Lead and provide direction in creating and managing advanced to complex data warehouse and analytics architectures
• Author and serve as subject matter expert to define requirements, standards and best practices

IS Data Warehouse Architect III

Translator

• Translate member materials from English to Spanish using computer-aided translation (CAT) software; written materials range from correspondence about benefits to educational materials.
• Adjust translation as needed to convey the style, tone, and intent of the text and produce culturally and linguistically appropriate materials.
• 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 submitted by vendors or contractors.
• Collaborate with copywriters, graphic designers, project managers, and reviewers on a daily basis to create products that meet all standards.
• Request clarification if there is any ambiguity to ensure the source text is transferred accurately into the target language.
• Balance time-sensitive deadline submissions with longer-term project deadlines.

Spanish Translator

• Perform Data Warehouse Architecture at an intermediate level
• Focus on design and development of data models and ETL specifications
• Conduct data analysis, system design and architecture, standards and policy administration
• Coordinate vendor relations and conduct product/vendor research
• Create moderate to advanced data models and ETL specifications
• Maintain documentation on design and operation
• Analyze data sources and recommend solutions
• Participate in long-term data warehouse and dashboard architecture planning
• Manage existing systems compliance with established standards

IS Data Warehouse Architect II

General

• Serve as liaison between CareOregon and the provider-partner network
• Focus on establishing and strengthening provider-partner relationships
• Conduct new provider orientations; train clinic office staff
• Cultivate relationships with providers to enhance access to quality care
• Conduct provider site visits to maintain relations and effectiveness

Provider Relations Specialist II

Medical Director

• implementing effective utilization review
• care management and clinical practice improvement initiatives
• lead medical management initiatives for the organization
• clinical quality in the provider network
• utilization, quality, case management and disease management operations
• monitor results in integration and behavioral health

Associate Medical Director – Behavioral Health

Security Engineer

• Lead the design and management of security technologies, including but not limited to firewalls, proxy systems, logging, and other security devices
• Provide security technology expertise to the organization; participate in and consult on projects
• Advise other IS teams on best practices for security design
• Execute tasks related to tickets and service requests for advanced to complex activities
• Oversee the maintenance of security systems, including firewalls, proxy systems, logging, and other security devices, and vendor provided services
• Analyze business needs; partner with leaders across the organization in order to research and recommend solutions which balance business need and risk mitigation
• Define, build, and review reports on information security system performance and event anomalies
• Author and serve as subject matter expert to define requirements and standards for information security
• Monitor and continually review existing systems to ensure they are designed to comply with established standards and to empower business operations
• Lead the planning for and support of disaster recovery and business continuity initiatives
• Conduct product and vendor research, and present recommendations to management
• Manage relations with vendors and equipment suppliers, including installation and repair of services
• Perform work in alignment with the organization’s mission, vision, and values

Information Security Engineer III

Health Coordinator

• Serve as the first point of contact within the Care Coordination Team for members or providers who call CareOregon Regional Care Team (RCT) phone lines requesting assistance with physical and behavioral health needs
• Answer phone lines and check voicemails left on RCT line daily and address any needs identified
• Coordinate referrals from members, providers, community partners, and internal CareOregon departments and teams
• Provide call escalation support for Customer Service Representatives when necessary
• Determine navigation, care coordination and/or resource needs in response to calls into the Regional Care Team (RCT) phone lines
• Identify members in crisis, triage needs requiring urgent attention, and help de-escalate high-need callers
• Triage appropriate referrals and help determine care coordinator assignment for RCT clinical care coordinators based on identified member needs
• Provide telephonic-based physical and behavioral health care coordination to eligible members and families
• Maintain a caseload of 10-20 members with ongoing physical and behavioral health care coordination needs
• Facilitate access and remove barriers to necessary care and services for members and families
• Facilitate communication among members, their support systems, clinical care providers, community partners, and internal CareOregon departments, ensuring care plans are shared as appropriate
• Coordinate effectively with interdisciplinary teams for integrated care plan support of complex member needs, participating in relevant team meetings
• Provide appropriate support to clinical Care Coordination staff involved with members
• Assist members in establishing and engaging with providers
• Refer members to appropriate agencies for community support
• Coordinate care for members residing outside of service area as required in contract
• Assist in transition and discharge planning for members moving from acute care, long-term care, or other residential facilities back to community-based supports as directed by clinical supervisor
• Take independent actions to address each member’s identified needs including (but not limited to): scheduling provider appointments, arranging for transportation, arranging for an interpreter, confirming authorizations/referrals, assisting with Health-Related Services Flex requests, verifying needed services are provided, referring to community resources and locating members
• Assess for and identify physical and behavioral health care coordination needs
• Identify and appropriately address risk factors and service needs that may impact member outcomes
• Utilize a trauma-informed approach to provide member-centric physical and behavioral health care and support
• Assist members in moving through the continuum of care based on clinical, medical, and behavioral health needs
• Use motivational interviewing to coach members toward improved physical and behavioral health care behaviors and self-management
• Utilize assessment information to develop individualized care plans for assigned members
• Coordinate with providers to ensure integrated physical and behavioral health care plans are timely, effective, and consider the members’ unique needs
• Implement physical and behavioral health care coordination plans in collaboration with the member, providers, case workers and other relevant parties
• Develop working partnerships with community health care providers concerning member needs and care plans
• Maintain compliance with Coordinated Care Organization (CCO) requirements
• Complete initial and subsequent documentation for care coordination activities and support clinical care coordinators in plan creation adhering to required timelines
• Maintain working knowledge of CareOregon Advantage (COA) and Oregon Health Plan (OHP) benefits, including Dental, Vision, Hearing, Addictions, and Mental Health benefits
• Report member complaints to Appeals and Grievance team for investigation and follow-up, per protocol
• Maintain compliance with the Model of Care requirements, if applicable
• Participate in quality and organizational process improvement activities and teams when requested
• Participate in work-related continuing education when offered or directed

Health Care Coordinator

Investigator

• administer fraud, waste, and abuse (FWA) duties for CareOregon
• perform fraud investigations
• provide regular FWA reporting
• develop and operate an effective FWA program in accordance with CMS requirements
• perform routine FWA investigations, audits, and corrective actions
• prepare reports of audit findings
• respond to routine and ad hoc requests from external regulatory agencies
• prepare routine and ad hoc reports for internal and external leaders
• assist in developing and maintaining documentation system for FWA regulatory requirements
• review and recommend policy and procedure revisions
• attend internal and external FWA and compliance-related meetings
• assist in providing effective FWA training and education to staff
• educate providers on appropriate documentation and coding

Special Investigations Unit Investigator

• Administer the fraud, waste, and abuse (FWA) duties at an advanced level
• Ensure effective measures are in place and operating effectively to prevent, detect, and correct fraud, waste, and abuse
• Perform advanced level of fraud investigations and provide regular FWA reporting to regulatory agencies
• Help ensure that appropriate procedures are in place and followed consistently to safeguard assets, verify accuracy and reliability of data, and promote efficient operations
• Contribute to the development and operation of an effective FWA program in accordance with CMS requirements and Federal Sentencing Guidelines
• Prepare reports of audit findings and recommendations
• Educate and coach leaders and staff regarding FWA requirements and complex issues
• Participate in completing required Medicare and Medicaid filings and/or responses for FWA

Senior Investigator, Investigations Unit

Claims Specialist

• Adjudicate medical, dental and mental health claims in accordance and compliance with plan provisions, state and federal regulations, and CareOregon policies and procedures.
• Re-adjudicate, adjust or correct claims, including some complex and difficult claims as needed.
• Consistently meet or exceed the quality and production standards established by the department and CareOregon.
• Provide excellent customer service to internal and external customers.
• Collaborate and share information with Claims teams and other CareOregon departments to achieve excellent customer service and support organizational goals.
• Determine eligibility, benefit levels and coordination of benefits with other carriers; recognize and escalate complex issues to the Lead or Supervisor as needed.
• Investigate third party issues as directed.
• May review, process and post refunds and claim adjustments or re-adjudications as needed.
• Report any overpayments, underpayments or other possible irregularities to the Lead or Supervisor as appropriate.
• Generate letters and other documents as needed.
• Proactively identify ways to improve quality and productivity.
• Continuously learn and stay up to date with changing processes, procedures and policies.

Claims Examiner II

Accountant

• Perform senior level accounting functions for the organization
• General ledger maintenance and analysis
• Prepare routine to complex general ledger journal entries
• Prepare monthly account reconciliations for complex accounts
• Review and analyze data to ensure accuracy and regulatory compliance
• Prepare monthly financial reporting packages
• Prepare external financial reporting, including regulatory filings
• Develop reports for ad-hoc requests using excel or GL software
• Participate in presenting financial statements at Finance Committee and Board meetings
• Support year-end audit request and assist in audited financial statement preparation
• Prepare financial reports as required by various regulatory agencies
• Develop and maintain effective working relationships with internal departments
• Support and train coworkers

Senior Accountant – Reporting & Analysis

Project Manager

• Develop project plans that outline components, communications, milestones, priorities, needs and resources
• Organize, facilitate, and participate in meetings of stakeholder groups
• Work collaboratively in analyzing business needs to identify potential technical solutions
• Apply senior level skills in leading stakeholders
• Monitor and regularly communicate project status to Sponsors, Business Owners and other stakeholders
• Make formal and informal presentations and reports
• Identify potential difficulties and/or barriers to project goals
• Ensure compliance with all applicable standards, policies, laws, rules and regulations
• Employ advanced change management techniques to facilitate the adoption of the project
• Maintain appropriate records, information, documentation and reports

Project Manager II

• Develop project plans that outline components, communications, milestones, priorities, needs and resources
• Organize, facilitate, and participate in meetings of stakeholder groups to identify needs and build consensus and collaboration
• Work collaboratively in analyzing business needs to identify potential technical solutions and process impacts to inform business case and project proposals and project plans
• Apply senior level skills in leading stakeholders; act as a resource to project team members
• Monitor and regularly communicate project status to Sponsors, Business Owners and other stakeholders, helping to ensure progress toward completion
• Make formal and informal presentations and reports, providing updates and other relevant information on the status of projects
• Represent the organization regarding project status and alignment with strategic plans; facilitate and work effectively to develop consensus within divergent groups and/or groups with divergent viewpoints
• Identify potential difficulties and/or barriers to project goals and take steps to mitigate or avoid them
• Ensure compliance with all applicable standards, policies, laws, rules and regulations outlined in the project plan
• Employ advanced change management techniques to facilitate the adoption of the project
• Track large scale project costs and identify variances from project plans
• Develop and recommend operational processes and/or process improvements including supporting information systems
• Maintain appropriate records, information, documentation and reports
• At the time of project completion, close files and review records to ensure documentation is appropriate and complete
• Facilitate the evaluation of progress and challenges following implementation, identifying potential system or process improvement opportunities
• Provide subject matter expertise and guidance for implementation, configuration and on-going support of internal systems, technology, and analytics

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

• 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