Clinical Operations Manager

Job Description

Job Description

SUMMARY

This position is responsible for managing Clinical Operations, including assuring medical and dental authorizations for members are processed timely and according to regulatory requirements. This position is also responsible for managing care coordination services assuring a personalized, timely, comprehensive, and cost-effective approach to the provision of medical and dental health related services. This position is responsible for overseeing compliance of state and federal requirements for associated work, including contractual requirements with the Medicaid plans by performing the following duties.

• Manages the medical and dental utilization review processes for members.
• Leads the management of contract deliverables and compliance related to utilization management and care coordination.
• Demonstrates knowledge of the Medicaid benefit packages and the ability to administer those benefits.
• Leads the process for identifying members with catastrophic, complex, and chronic medical management needs and leads assessment and delivery of potential options and alternatives for management of specific health related needs.
• Oversee the coordination of care across a continuum of care settings to assure appropriate care and achievement of optimal outcomes.
• Manages the processing of authorization requests for dental, medical specialty and ancillary referrals, hospitalization authorizations, durable medical equipment, skilled nursing facility placements, inpatient rehabilitation, long term care stays, and home health services.
• Oversees the determination of appropriate level of care and quality of care and collaborates with the team to identify alternative levels of care for members.
• Works with the Director of Clinical Operations and Chief Medical Officer in reviewing complex cases and authorization requests.
• Ensures a coordinated approach to care planning and appropriate use of healthcare resources.
• Supports the process of utilization management with local and out-of-area providers.
• Assures that utilization review team initiates referral to care coordination team as appropriate.
• Reviews reports on high-cost utilization by individual members, including emergency department, hospital costs, outpatient services, and readmissions, and identifies and manages utilization review interventions to reduce costs for those members.
• Facilitates an orderly and timely transition from one care setting to another and member transitions to other Coordinated Care Organization (CCO) or other plans.
• Prevents lengthy hospitalization by ensuring effective and efficient care coordination to optimize outpatient care and remove barriers to discharge, thus avoiding costs and risks encountered in institutional settings.
• Attends and participates in or, assures department representation in, meetings with department managers for primary care clinics, hospitals, Skilled Nursing Facilities, and local DHS to facilitate care coordination and access to care.
• Collaborates with other departments and providers to improve communication and processes related to utilization management and care coordination activities.
• Supports the work of the Quality Department to improve performance on Oregon Health Plan quality measures where applicable.
• Participates in process improvement projects and assists with maintaining department operating instructions and procedure manuals related to utilization management and care coordination.
• Maintains confidentiality and complies with HIPAA rules and regulations.
• Maintains punctual, regular and predictable attendance.
• Works collaboratively in a team environment with a spirit of cooperation.
• Displays excellent communication skills including presentation, persuasion, and negotiation skills required in working with members and coworkers and including the ability to communicate effectively and remain calm and courteous under pressure.
• Respectfully takes direction from manager.

EDUCATION and/or EXPERIENCE

Bachelor's degree from a four-year college or university in a related field; and three to five years related experience and/or training; or equivalent combination of education and experience.

CERTIFICATES, LICENSES, REGISTRATIONS

A valid Oregon Registered Nursing (RN) license is required. A Certified Case Manager (CCM) certificate or equivalent is required within eighteen months.

COMPUTER SKILLS

Job requires specialized computer skills. Must be adept at using various applications including database, spreadsheet, report writing, project management, graphics, word processing, presentation creation/editing, communicate by e-mail and use scheduling software.

We provide a competitive salary and excellent benefits, including vacation, medical, dental and vision insurance, and 401(k) pension plan. To apply for this position, please submit a cover letter and resume. We are an Equal Opportunity Employer.

Hybrid Position

Background Check & Drug Screen Required