CareOregon

• 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

Role Description The Training Specialist I is responsible for providing job-related training and guidance for employees within the assigned functional area. Functional areas of focus may include customer service, claims, clinical operations, behavioral health, enrollment and/or provider services. The core responsibilities include: - Facilitating and conducting instructor-led classes (virtually and/or in person) or other learning opportunities and resources with individuals and groups. - Contributing to and growing in the ability to design and develop written and visual course materials. - Creating and maintaining measurement tools to help ensure learning goals are met. - Assisting other CareOregon teams as assigned and available. Qualifications - Minimum 2 years’ experience in the insurance or healthcare industry (e.g., claims, customer service, managed care, healthcare facilities, etc.); experience must include training delivery, as well as assisting in creating learning program content and materials. - Experience working with processes and policies in assigned functional area (preferred). - Coursework in learning and development (preferred). Requirements - Basic knowledge of or ability to learn adult learning theory, practices and principles. - Basic knowledge of or ability to learn human performance theories and practices. - Basic knowledge of or ability to learn principles of organizational change and ability to act as a change agent. - Knowledgeable about procedures in area of focus. - Knowledge of or ability to quickly learn the basic concepts of managed health care. - Strong verbal and written communication skills; comfort communicating with all levels of employees. - Ability to clearly present information to small and large groups. - Ability to facilitate learning opportunities in informal and formal settings to small and large groups. - Growing ability to incorporate process improvement learning and theories into trainings. - Growing ability to design appropriate learning opportunities based on needs assessment and principles of instructional design and rapid prototyping. - Ability to integrate excellent customer service skills. - Strong planning and organizational skills. - Problem-solving, decision-making and process improvement skills. - Ability to gather and interpret data. - Ability to work well under pressure in a complex and rapidly changing environment. - Ability to function autonomously and to effectively set priorities. - Ability to use Microsoft Word, Excel, Outlook, SharePoint and Teams. - Ability to accept direction and feedback, as well as tolerate and manage stress. - Ability to learn, focus, understand, and evaluate information and determine appropriate actions. - Ability to work effectively with diverse individuals and groups. - Ability to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day. - Ability to lift, carry, reach, and/or pinch small objects for at least 1-3 hours/day. Benefits - Competitive pay and 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, wellness program, and discounts. - 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.

• Perform data warehouse architecture or enterprise data architecture at a senior level. • Design and develop data models and ETL specifications. • Conduct data analysis and system design. • Author and monitor standards and policy administration. • Coordinate with vendors and manage relations.

• 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.

Role Description This position is responsible for coordinating dental referrals and pre-authorizations for PDP and specialty network affiliates. Core tasks include: - Reviewing, processing, approving and matching members to the most appropriate specialty dental services. - Improving member access to specialty care and provider network support. - Providing customer service and general support to the dental team as assigned. Qualifications - Minimum 3 years’ experience in the dental industry. - Experience with dental provider networks, dental coding, dental clinic operations, and/or scheduling. - Preferred: Candidates must be located in the Portland, Oregon and/or Vancouver, Washington area. Requirements - Knowledge of or ability to quickly learn the following: - Oregon Health Plan and Medicaid Dental benefits. - Covered/non-covered dental services and OARs. - Dental terminology, dental charting, and dental coding. - Dental clinic operations. - Excellent customer service, written and verbal communication skills. - Excellent critical thinking skills. - Exceptional interpersonal and organizational skills that foster collaboration. - Ability to effectively solve unique problems as they arise or identify when to escalate issues to appropriate department/supervisor. - Ability to develop and maintain excellent professional working relationships with PDPs and specialists. - Ability to take accountability and initiative. - Ability to support and comply with organizational policies, procedures and guidelines. - 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, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day. Benefits - Competitive pay and 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, wellness program, and discounts. - 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.

• 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

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. NOTE: This position focuses on Appeals and Grievance. 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 the functional focus area (Appeals and Grievance, Benefits Review or Benefit Management) (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

Role Description This position is responsible for providing outreach, dental care coordination and cross-system, population health coordination for the organization’s dental and oral health benefits. Core work involves providing care coordination and case management for dental members including: - Assessing member needs and coordinating with providers and members. - Internally assigned and outbound case management and navigational support for dental members. - Partnership with internal teams relating to cross-disciplinary care needs for individual members. - Working directly with members to support identified health needs, particularly oral health. - Ensuring dental benefit and provider access awareness for members and their families. - Supporting navigation and coordination to dental providers or other care teams as needed. - Partnering with internal teams and external partners to assure timely access to dental care. - Maintaining continuity of care and optimizing member well-being. This position requires critical thinking, time management, strong written and verbal communication skills, and independent judgment as well as comfort working with the organization’s most vulnerable members. NOTE: This position requires residing in the Portland metro area. Qualifications - Expanded Function Dental Assistant (EFDA) certification or equivalent clinical experience. - Minimum 3 years’ experience in the dental healthcare setting with a combination of patient care and other experiences, including dental health insurance, treatment plan or case presentation, care coordination, front office and dental clinic operations, dental scheduling, coding, metrics, referral, and/or insurance authorization processes. Requirements - Knowledge of clinical dental care, dental procedures and clinical workflow. - Understanding of the relationships and co-morbidity of oral health and systemic health. - Knowledge of the Oregon Health Plan and Medicaid Dental benefits. - Knowledge of covered/non-covered dental services and OARs. - Knowledge of dental terminology and dental coding. - Understanding of dental provider networks. - Familiarity with dental clinic and financial operations. - Ability to discuss dental procedures and treatment plans with patients and interdisciplinary clinical teams. - Exceptional interpersonal and organizational skills. - Excellent written and verbal communication skills, including motivational interview skills. - Ability to work effectively across multiple departments and health disciplines. - Ability to develop and maintain excellent professional working relationships with PDPs and specialists. - Ability to support and comply with organizational policies, procedures, and guidelines. Benefits - Competitive pay and 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, wellness program, and discounts. - 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.

Role Description The Clinical Systems Trainer is responsible for training staff in the correct and effective use of decision tools used for utilization management activities and assess staff readiness to begin their specific role in the Division at the conclusion of training. As new initiatives and functionalities arise, they work jointly with Clinical Operations leadership to identify training opportunities and implement strategies to ensure ongoing training needs are met. They are responsible for onboarding and orientation of new clinical employees to clinical guideline tools (InterQual); they author guidelines from regulatory requirements or customize from nationally recognized clinical content or organizational criteria to meet CareOregon’s needs. They lead the ongoing training of clinical staff as new guidelines are developed. They develop training and reference materials to ensure staff have the tools needed to streamline operational workflows and overall meet regulatory compliance. They support audit activities as requested. Qualifications - Registered Nurse (RN) license - Minimum 2 years of clinical experience working with clinical guidelines - Experience in clinical content creation or medical writing (Preferred) - Experience with InterQual (Preferred) - Experience with training and onboarding (Preferred) Requirements - Conduct onboarding training sessions for newly hired clinical staff in utilization management workflows. - Develop and maintain job aids to support core workflows. - Facilitate remediation training for identified deviation by individuals and/or teams from policies, procedures, and processes. - Lead ongoing training refresher sessions for clinical staff. - Build evaluation of staff training and provides feedback to respective managers. - Responsible for departmental reporting of aggregate training activities. - Track all activities which can be used as support documentation for CMS or OHA audits. - Identifies training opportunities and implements strategies to ensure ongoing training needs are met. - Assist in internal and external audits as requested. - Implements strategies to ensure staff comply with internal or external plan of corrections. - Develop, review, and update clinical content, ensuring accuracy and relevance. - Ensure all content complies with current clinical standards and regulations. - Maintain up-to-date knowledge of clinical practices and Medicare and Medicaid guidelines. - Assist in the development of training materials and educational resources. - Participate in quality improvement initiatives and projects. - Design, develop, and update clinical content through the review and understanding of information gathered from regulatory and organizational requirements. - Collect and incorporate feedback from internal customers to ensure clinical accuracy and usability. - Perform Quality Assurance testing of clinical content and create and maintain clinical documentation. - Serve as a clinical resource for both internal customers, including training of new content both created and as part of the product. - Collaborate with Medical Directors and Clinical Operations leadership team for organizational criteria. - Participate in developing project plans, monitoring tasks and ensuring on-time delivery of clinical content. 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) - 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

Role Description This position is responsible for administering the fraud, waste, and abuse (FWA) duties for CareOregon and its affiliated lines of business. Core work includes ensuring effective measures are in place and operating effectively to prevent, detect, and correct any instances of fraud, waste, and abuse. This includes performing fraud investigations and providing regular FWA reporting. Additionally, this position helps ensure that appropriate procedures are in place and followed consistently to safeguard its assets, verify the accuracy and reliability of data, and promote efficient and effective operations. Estimated Hiring Range: $72,765.00 - $88,935.00 Bonus Target: Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. Qualifications - Minimum 2 years’ experience in FWA, compliance and/or audit including in an operational setting within a highly regulated industry - Oregon Medicaid experience or health plan experience (Preferred) - CPC (Certified Professional Coder) or RHIT (Registered Health Information Technician) or CFE (Certified Fraud Examiner) (Preferred) Requirements - Assist in the development and operation of an effective FWA program in accordance with CMS requirements, OHA/OHP requirements, and applicable laws with guidance from department leadership. - Perform routine FWA investigations, audits, and corrective actions as assigned, including maintaining documents and providing routine updates; may assist senior investigator with more complex or advanced investigations. - Prepare reports of audit findings; provide recommendations regarding improvements or corrective actions where a deficiency may exist. - Prepare, proofread, and distribute correspondence, forms, and other information of a specialized and confidential nature. - Respond to routine and ad hoc requests from external regulatory agencies as assigned, such as annual reviews, quarterly reports, and one-off requests. - Prepare routine and ad hoc reports for internal and external leaders, committees, and governing body, including collecting, analyzing, and displaying data. - Assist in developing and maintaining an organized, methodical documentation system for communicating, implementing, and administering new and existing FWA regulatory requirements. - Review and recommend policy and procedure revisions that support the FWA/SIU program. - Attend internal and external FWA and compliance-related meetings as assigned. - Assist in providing effective FWA training and education to staff, both internal and external. - Educate providers on appropriate documentation and coding. - Participate in FWA program-related risk assessment and mitigation processes. - Meet departmental metrics for key performance indicators. 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, wellness program, discounts, and multiple supplemental benefits - 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