Responsible for oversight of defined Health Services programs, services, or functions including utilization management, claim review, and policy/procedure development. May be called upon to perform routine day-to-day program functions. Actively participates in program development and implementation. Supervises and provides guidance to direct reports and other department staff regarding guidelines, policies, procedures, and operations. Manages the quality and productivity of team responsibilities and workflow as they relate to both assigned functions and the overall effectiveness of the Health Services team. Works to resolve issues and improve processes and outcomes. Ensures member satisfaction and helps to establish service best practices. Supports and develops department vision and commitment to Health Services goals.
Internal and External Liaison:
LEAN process management and Program Management:
Compliance and Regulatory Oversight:
Work Experience: Five years clinical experience. Minimum of three years direct health plan experience in the following areas: case management, utilization management, behavioral health, and/or disease/condition management. Prior supervisory experience preferred.
Education, Certificates, Licenses: Registered Nurse or Licensed Clinical Social Worker with current appropriate unrestricted state License.
Knowledge: Knowledge of health insurance and state mandated benefits. Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedure codes (including ICD-10, HCPC CPT codes), health insurance and State of Oregon mandated benefits. Effective adult education/teaching and/or group leadership skills. Ability to deal effectively with people who have various health issues and concerns. Strong analytical and organizational skills with experience in using information systems and computer applications. Is flexible. Ability to develop, review, and evaluate utilization and case management reports. Good computer skills including experience with Word, Excel, and PowerPoint. Ability to use audio-visual equipment. Ability to work independently with minimal supervision.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.