Job Title Quality Assurance and Compliance Manager Exemption Status Exempt Department Transportation Manager Title Director of Transportation Direct Reports Quality Assurance and Compliance Specialist, Grievance System Specialist Requisition # 24307 Pay & Benefits Estimated hiring range $96,950 - $117,315, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits Posting Notes This is a Hybrid role, traveling within Oregon – to any of our 3 sites; Downtown Portland, Medford & the Oregon Coast at least 1x/month. Job Summary This position is responsible for quality assurance operational activities for Transportation services covered under Medicaid and Medicare lines of business, including appeals and grievances, as well as data reporting. This includes Non-Emergent Medical Transportation benefit administration as well as quality assurance for transportation services for social health services and programs supplementing covered benefit programs. This position manages non-clinical teams. Additionally, the Quality Assurance & Compliance Manager staffs NEMT Quality Assurance workgroups, participates in Oregon Health Authority and CO Quality Committees and assists in plan-wide regulatory activities. Essential Responsibilities Operations and Planning
Develop and oversee implementation of policies and procedures related to responsible areas to meet Medicaid and Medicare contracting requirements and organizational needs. Collaborate with other members of the Transportation team to provide content updates or review other policies as needed.
Assist the Director and collaborate in partnership with the Transportation Manager in the development of short and long-term quality planning.
Guide appeals and grievances work across Transportation team and subcontracted partners and vendors.
Manage regulatory functions of the department.
Create and assist in maintaining evaluation tools.
Review data and information to identify improvement opportunities, guide staff in the implementation of subcontractor and program improvements.
Keep abreast of standards for health plan quality operations related to responsible areas and develop plans to operationalize.
Keep abreast of all Medicare/Medicaid/NCQA regulatory expectations and inform staff and stakeholders of those changes.
Contribute to and/or recommend the creation of subcontractor performance improvement or corrective action plans as needed related to issues identified with contract performance.
Appeals and Grievances
Provide technical leadership for appeals and grievances.
Oversee department and subcontractor compliance of regulatory timelines for grievance and appeal resolution.
Provide direction for Transportation team technical assistance to ensure all Medicare/Medicaid/NCQA regulatory expectations are adequately integrated into subcontracted partners and vendors.
Provide guidance to the Transportation team in the development of processes and improvements.
Cross Functional Collaboration
Work collaboratively with other relevant CareOregon departments.
Participate in workgroups/ meetings related to regulatory expectations.
Work with Information Systems on reporting requirements.
Committee Leadership and Participation
Staff the NEMT Quality Assurance workgroups; participate in Oregon Health Authority and CO Quality Committees as requested.
Oversee data collection and report production for teams, including regulatory and data to support audits, including OHA, CMS, and Internal audits.
Ensure all data reporting is assessed for quality, completeness and accuracy per specifications of requestor.
Employee Supervision
Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
Train, supervise, motivate, and coach employees; provide support toward employee development.
Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.
Ensure team adheres to department and organizational standards, policies, and procedures.
Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
Perform supervisory tasks in collaboration with Human Resources as needed.
Organizational Responsibilities
Perform work in alignment with the organization’s mission, vision and values.
Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
Strive to meet annual business goals in support of the organization’s strategic goals.
Adhere to the organization’s policies, procedures and other relevant compliance needs.
Perform other duties as needed.
Experience and/or Education
Required
Minimum 5 years’ experience in quality assurance operations
Preferred
Minimum 2 years’ experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon’s Aspiring Leaders Program
Preference may be given to candidates with Medicare and Medicaid experience in a health plan setting, delivery system and health plan quality experience
Knowledge, Skills and Abilities Required
Knowledge
Strong knowledge of health plan operations
Knowledge of health plan regulatory requirements of Medicaid and Medicare managed care
Knowledge of managed care concepts and principles
Knowledge of organizational improvement principles and practices
Knowledge of principles of organizational change and ability to act as a change agent
Knowledge of quality improvement concepts, principles and practices
Skills and Abilities
Ability to mentor team members and foster growth
Ability to provide leadership to groups of people and to the implementation of projects
Ability to develop, support and comply with organizational policies, procedures and guidelines
Ability to use basic computer programs commonly used for health plan quality operations
Strong comfort with Microsoft Word, Excel, and email
Ability to work well under pressure and meet deadlines in a complex and rapidly changing environment
Detail oriented, with a focus on record keeping and reporting
Excellent reading, oral and written communication skills; ability to build consensus
Excellent interpersonal skills
Excellent problem solving and decision-making skills appropriate to the situation
Ability to understand, lead, and follow established departmental policies and procedures
High degree of personal initiative and motivation along with the ability to effectively collaborate with the organization’s leadership and reporting staff
Ability to present a positive and professional image
Skilled in building consensus
Work independently and make decisions appropriate to the situation
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
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 .
#LI-Hybrid
Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.
Veterans are strongly encouraged to apply.
We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.
Visa sponsorship is not available at this time.