CareOregon

• 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.

• 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

• 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

• 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

• 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

• 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.

Role Description The Registered Nurse - Utilization Management I is responsible for supporting specific utilization management (UM) program functions within the Clinical Operations department. UM program functions include Benefit Management, Benefit Review, Appeals and Grievances, and Health Related Services (HRS). Together they support the healthcare needs of members, determine the best medically appropriate services, and apply clinical-based criteria for decision-making while managing medical expenses. Estimated Hiring Range: $102,330.00 - $125,070.00 Bonus Target: Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. Qualifications - Current unrestricted Oregon RN license - Minimum 2 years RN experience [OR 1 year RN experience AND 3 years’ experience in healthcare setting role(s) such as billing, coding, medical assistant, etc.] - More than 1 year RN experience (preferred) - Healthcare utilization management experience in Prior Authorization UM (preferred) - Experience with Medicaid and/or Medicare utilization management (preferred) Requirements - Communicate with members and/or providers in a professional manner and in accordance with State and Federal requirements as needed to complete requests. - Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards. - Refer members to care coordination per policies and procedures. - Maintain accurate and complete documentation. - Collaborate with Medical Directors to determine medical necessity and appropriateness of care for benefits requested and/or rendered. - Work with clinical support staff to ensure service requests, authorizations and/or grievances are managed in accordance with state and federal guidelines. - Identify and refer potential quality of care issues for peer review. - Ensure that authorization decisions are based on organizational policy and state and federal coverage rules. - Gather and submit documents for third party case review; this includes all documentation and follow-up activities. - Issue denial notices based on established unit protocols and state and/or federal requirements. - Assist with periodic audits, general quality management and improvement activities, and other regulatory activities as needed. - Foster collaboration with teams across the Clinical Operations department to ensure work and goals are met. - Meet or exceed department production, timelines, and quality standards established for level I. - May participate in departmental workgroups or projects as assigned. - Support testing for system updates and implementations as assigned. - May help train new staff and teammates as assigned. - Cross train in additional functional focus areas as assigned. Benefits - Competitive pay - Bonus opportunity - Comprehensive benefits package including medical, dental, vision, life, AD&D, and disability insurance - Health savings account, flexible spending account(s), lifestyle spending account - Employee assistance program and wellness program - Discounts and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.) - Strong retirement plan with employer contributions - PTO and Paid State Sick Time based on hours worked/scheduled hours - Paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility - 401(k) contributions for non-benefits eligible employees Company Description CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.

• 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

• 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

Role Description This position is responsible for leading large scale, complex projects or programs utilizing project management and LEAN principles and techniques. Work comprises all stages of the project lifecycle, including scoping, planning, management, and implementation. Projects frequently have a technology focus. Under minimal supervision, this position acts as a liaison between internal and external partners, contractors and stakeholders to facilitate collaboration, consensus building and help ensure accountability, as well as maintain technical project reports, records and documentation. This is an expert level project management position and typically leads projects in support of highly integrated, enterprise-wide initiatives or programs comprised of multiple interrelated projects. These frequently have varied and numerous participants, areas of high ambiguity, and competing priorities and/or interdependencies with other projects. Essential Responsibilities - Planning and Development - 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. - Project Management - Apply expert 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. - Quality Assurance - 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. - Implementation - Employ advanced change management techniques to facilitate the adoption of the project. - Track program and/or large-scale project costs and identify variances from project plans. - Develop and recommend operational processes and/or process improvements including supporting information systems. - Documentation and Evaluation - 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. - Administration - Actively participate in business unit planning and performance metrics. - Recommend and draft policies and procedures for departmental or organizational application. - Participate in functional discussions and initiatives across departments. Qualifications - Minimum 7 years’ related experience, including minimum 5 years managing projects; experience should include: - Independent leadership of a variety of medium and large-scale projects, as well as leadership on occasional enterprise-wide, complex projects. - Minimum 5 years’ experience leading information systems projects, including some at a complex level. - Minimum 2 years’ experience in the health care or managed care industry. - Preferred: - Scrum, Agile, and/or Project Management International (PMI) Project Management certification. - 3 or more years’ experience in health plan operations. - Smart Sheets experience. - Experience with both Technical and Operational projects. - Candidates located in Oregon preferred. Knowledge, Skills and Abilities Required - Knowledge - Thorough knowledge of principles, methods, and techniques of project management and effective organizational change management. - Working knowledge of policies, principles, and practices of healthcare and health insurance. - Advanced understanding of multiple health plan functions and system implications. - Advanced knowledge of multiple project management frameworks, specifically variations of both agile and waterfall development methods. - Skills and Abilities - Ability to integrate process improvement and redesign principals and techniques such as Lean, PDSA, or Six Sigma. - Expert ability to develop a formal and detailed project plan aligned with established timeline and budgetary guidelines. - Advanced ability to lead and motivate peers, cross-functional partners and management toward project goal attainment. - Excellent ability to manage multiple activities, matrixed teams, organization communications, and frequently competing priorities to implement change as necessary within time and budget constraints. - Excellent skills in Microsoft Office, collaboration and project planning systems. - Highly skilled at resource planning and negotiating with resource managers for needed skills and time from team members throughout the project/program lifecycle. - Expertise with information systems in the health insurance or related industry preferred. - Excellent communication skills, including listening, verbal, written, documentation, meeting facilitation, and presentations. - Ability to maintain a high degree of professionalism in working with internal and external business partners. - 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 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. Benefits - We offer a strong Total Rewards Program, including competitive pay, bonus opportunity, and a comprehensive benefits package. - Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. - Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. - CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits. - We also offer a strong retirement plan with employer contributions. - Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. - Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. - Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Company Description CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.