Health Services Manager - RN | Flexible Hybrid: Virtual and In-Person

Remote - Flexible Hybrid: (Remote and In-Person) McMinnville, OR

COVID-19 vaccination required for all YCCO employees except for an approved accommodation for medical or sincerely held religious belief. Please see Additional Information below.

Department:   Health Services                                         FLSA Status:                Exempt

Reports To:     Chief Medical Officer (CFO)                      Physical Strength:      Light (L)

Summary

The Health Services Manager is responsible for managing clinical collaboration across the department, external entities and with members, providers, and other community stakeholders. Key functions of the position include overseeing and ensuring Oregon Health Authority (OHA) members care coordination and utilization management needs are met, ensuring health service programs operate efficiently, and proactively assisting with external quality review activities as applicable. Key partners in this process are the member and relevant family/caregivers, the member’s providers, external vendors, Oregon Health Authority (OHA), and other providers, appropriate community partners and internal operational staff.  Ensuring that the health, utilization management, and care coordination services are evidence-based and culturally specific.

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Essential Duties

1. Overseeing and ensuring OHP members care coordination and utilization management needs are met.

2. Ensures health service programs operate efficiently. 

3. Proactively assisting with external quality review activities as applicable.

Job Duties

Clinical Systems

  • Develops and leads the implementation of clinical quality and compliance, care management, and utilization management policies and procedures that meet Medicaid contract requirements.
  • Educates staff and external partners on the strategic and operational direction of clinical programs for the organization.
  • Works to ensure integration of health services across programs and systems of care.
  • Leads partnership and collaboration with key stakeholders including primary care and community health care providers and staff,  Aging and People with Disabilities caseworkers, OHA Innovator Agents and Client Services Unit staff, business partners, vendors, community agencies, and other relevant parties.  

Health Plan Services

  • Oversees and ensures a collaborative approach with all disciplines internal and external to demonstrate a client-centered approach to working with members.
  • Evaluates all relevant information including health risk assessments to determine the physical, behavioral, social support, and medical needs of the member.
  • Provides culturally and linguistically appropriate services to members engaged in health service programs.
  • Develops individualized care plans for high-risk members and participates in Multi-disciplinary Team Meetings (MDT) with all involved care team entities and member/caregiver as appropriate, to coordinate care services members.
  • Oversees hospital/facility discharge planning, care transitions, medication management and coordination activities.
  • Ensures members receive timely access to providers and services.
  • Creatively utilizes available community resources as an adjunct to health plan benefits and follows-up to determine if these are received by the member.

Utilization Management

  • Monitors health services activities related to clinical practice guidelines, authority of preauthorization, service requests, appeals, and final adjudication activities.
  • Facilitates internal utilization management activities, including utilization review, adaptation of clinical policies, response to trends of over or under service utilization, and monitoring performance of subcontracted partners.
  • Works with Grievance and Appeals Coordinators to review, take action, and ensure system compliance with service requests/authorizations/complaints are managed in accordance to State, Federal, and contract requirements.

Population Health

  • Oversees internal staff involved in population health related activities.
  • Participates in internal and external improvement initiatives related to clinical disciplines and health services activities.

Regulatory Compliance

  • Performs clinical reviews and supports internal monitoring and external quality review audits, including HEDIS and the detection of over and/or under utilization of services.   
  • Directs the data collection, analysis, and summary of health data for required reporting and public presentations.
  • Utilizes risk management tools and clinical experience to ensure clinical issues are addressed in a timely and thorough manner, to investigate adverse events, and identify system improvements.
  • Maintains confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards.
  • Understands and operationalizes contract language, Oregon Administrative Rules (OARs), Code of Federal Regulations (CFRs), Oregon Regulatory Statutes (ORSs) and other regulations as applicable.
  • Maintains program compliance with all contract and regulatory requirements.
  • Works closely with other YCCO’s departments, including the Quality Assurance and Compliance Department, to assist with subcontractor monitoring, oversight, and audits as needed.

Management & Leadership

  • Ensures program expectations and standards are clearly understood by unit staff.
  • Provides staff with the training, tools, and resources necessary to carry out their work.
  • Analyzes staffing needs and reorganizes work and assignments, as needed.
  • Supervises assigned unit staff in a consistent manner.
  • Evaluates unit employees’ performance both informally and formally and takes corrective action to address areas of opportunity.
  • Performs human resource functions in collaboration with the Supervisor and Human Resources.

Essential Department & Organizational Functions

  • Serves as the team leader for members with care coordination needs.
  • Works with other YCCO staff or partners as needed for care coordination.
  • Forwards relevant information of members requiring special consideration of benefits to  Chief Medical Officer for review. 
  • Makes referrals to established community programs as appropriate.
  • Collaborates with community partners to achieve improved health status for member populations.
  • Follows team, departmental, and organizational policies, and procedures.
  • Participates in quality and organizational process improvement activities and teams when requested.
  • Maintains strict confidentiality, observing all HIPAA rules.
  • Participates in work-related continuing education when offered or directed.
  • Proposes and implements process improvements.
  • Meets deadlines for completion of workload.
  • Maintains agreed upon work schedule.
  • Demonstrates cooperation and teamwork.
  • Provides coaching and cross-training on specific job responsibilities.
  • Meets identified business goals that contribute to departmental goals.
  • Maintains punctual, regular, and predictable attendance.  
  • Works collaboratively in a team environment with a spirit of cooperation.
  • Respectfully takes direction from Supervisor.
  • Other duties as assigned.

Knowledge, Skills, & Abilities

  • Knowledge of the Oregon Health Plan benefit package, eligibility categories, and Oregon Health System Division (HSD) rules and regulations.
  • Knowledge of ICD, CPT, and HCPCS codes.
  • Maintain working knowledge of OHP benefits, including Addictions and Mental Health services and Programs, drug formularies, and basic concepts of managed care.
  • Knowledge of culturally specific issues, resources, and strengths of the populations.
  • Competency in the use of motivational interviewing.
  • Knowledge of program requirements for OHP populations.
  • Ability to understand complex medical and behavioral health diagnostic information to assist providers and other care coordinators.
  • Excellent organizational skills and ability to manage multiple tasks and timelines simultaneously, as well as to perform work with attention to detail.
  • Ability to work independently, when needed, and to use sound judgment, anticipate next steps and be proactive.
  • Ability to collaborate with a variety of professional and technical staff maintaining a customer service orientation and function under potentially tight timelines.
  • Ability to exercise sound clinical judgment, independent analysis, critical thinking skills, and knowledge of health conditions to determine best outcomes for members.
  • Ability to establish collaborative relationships, work autonomously and effectively set priorities and work in an environment with diverse individuals and groups.
  • Ability to effectively lead a multidisciplinary team and manage multiple tasks and remain flexible in a dynamic work environment.
  • Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
  • Excellent verbal and written communication and basic word processing skills.

Supervisory Responsibilities

Directly supervises employees in the Health Services department. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education & Experience

Required:

  • Bachelor’s degree in Nursing
  • Current unencumbered license as a registered nurse (RN) in the State of Oregon
  • Minimum 2 years’ RN care coordination experience
  • 3 to 5 years’ experience supervising or leading staff

    OR

  • Any combination of education and experience that would qualify candidate for the position.

Preferred:

  • Experience in case management of OHP, Coordinated Care Organization (CCO) and/or Medicare members
  • Experience with a similar population in health plan case management or managed care coordination
  • Experience administering the Oregon Health Plan (Medicaid) and the Centers for Medicare and Medicaid Services (Medicare) benefits
  • Experience in the use of Motivational Interviewing and Certification as a case manager

Certificates, Licenses, and/or Registrations

Must have a current, unencumbered RN license in Oregon or the ability to obtain one.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds. 

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate. 

This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.

Additional Information about COVID-19 Vaccination Requirements

To safeguard the health of our employees and their families; our members and visitors; and the community at large, YCCO requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious accommodation as a qualification of employment.

Job candidates that receive a contingent offer of employment from YCCO must provide proof of COVID-19 vaccination, along with a completed attestation that the documentation submitted is true and correct to Human Resources Department;

OR

Submit a completed request for accommodation form due to a medical reason or sincerely held religious belief to the Human Resources Department to begin the interactive accommodation process.