CareOregon

Clinical Supervisor

• Supervise a remote team of RNs in Prior Authorization or Benefit Review
• Oversee referral management, authorization requirements, reinsurance reporting, and inpatient review processes
• Assist with policy and procedure creation and lead implementation of program changes
• Monitor staff competency and production levels
• Perform RN staff duties during coverage needs or work reassignment
• Identify process improvement opportunities and evaluate approved program changes
• Monitor OHP, DMAP, and Medicare rules and communicate changes to stakeholders
• Attend state and other utilization and review meetings and report to the Manager and department
• Ensure service requests and authorizations comply with OHP, Medicare, and coverage determinations
• Develop unit and training materials
• Complete utilization and review reports
• Orient and train new employees and provide ongoing staff training
• Recommend and implement technology improvements; maintain knowledge of QNXT and SharePoint
• Draft technology assessments for Medical Director review
• Act as a resource for department staff and Medical Directors
• Support financial-impact initiatives and collaborate across CareOregon departments
• Identify cases requiring Chief Medical Officer review
• Assign reinsurance reviews based on high-dollar case identification
• Supervise, coach, evaluate, and develop employees
• Plan and monitor staffing, schedules, goals, performance, and corrective action in collaboration with Human Resources

RN Clinical Benefit Management Supervisor

Operations

• Coordinate operations and processes for Coordinated Care Organizations and CareOregon transportation functional areas
• Help ensure service quality, program compliance, and effective communication among CCOs, CareOregon functions, delegated entities, providers, and internal departments
• Coordinate transportation operations and assist with vendor, partnership, and project management activities
• Coordinate program data and support compliance with internal policies and procedures
• Interpret impacts of regulatory requirements, guidance changes, and contractual updates on operations
• Coordinate policy, workflow, standard operating procedure, and program-tool updates
• Review and clean NEMT encounter and claims data and coordinate vendor data remediation
• Coordinate development of brand, marketing, and communication materials
• Gather and enter data for program and project status reports
• Coordinate program integrity activities, audit validation, utilization data collection, and monitoring reports
• Assist with meeting scheduling, agenda topics, and co-facilitation of internal and external meetings
• Provide technical support for NEMT operational benefit education and identify systemic support issues
• Support vendor and partner meetings through scheduling, agenda creation, and note-taking
• Track vendor, partner, and subcontractor performance success stories and gaps
• Coordinate member transportation activities and services
• Coordinate project and process improvement activities, timelines, status updates, and contributor information
• Use project management and process improvement tools
• Maintain tracking activities for vendor, partner, and subcontractor operations

Transportation Operations Coordinator

Business Analyst

• Lead complex business analysis efforts for strategic initiatives within the Transformation Management Office, Strategic Growth and Resilience portfolio, and other enterprise priorities
• Serve as a trusted advisor to business and organizational leaders
• Elicit, analyze, validate, and manage complex business needs, requirements, risks, dependencies, and success measures
• Translate enterprise strategies and operational challenges into business capabilities, requirements, decision frameworks, and implementation roadmaps
• Facilitate executive workshops, stakeholder engagement, and cross-functional requirements activities
• Establish traceability between strategic objectives, business value, solution design, implementation outcomes, and benefit realization
• Identify enterprise risks, organizational impacts, dependency conflicts, and readiness considerations
• Lead demand intake, strategic initiative assessment, portfolio planning, and investment prioritization
• Develop and maintain business cases supporting enterprise investment decisions
• Contribute to governance processes, stage-gate reviews, roadmap development, portfolio sequencing, and strategic prioritization
• Lead process analysis and large-scale process improvement efforts
• Establish value realization frameworks, benefit tracking strategies, performance measures, and success criteria
• Integrate operational, financial, customer, regulatory, and performance data into strategic recommendations
• Lead post-implementation assessments and recommend enterprise-level enhancements
• Communicate complex business issues, risks, impacts, and recommendations to executive and senior leadership
• Provide oversight for testing strategy, business readiness, implementation planning, and solution adoption
• Establish documentation, quality, consistency, and governance standards
• Mentor and coach junior Business Analysts and stakeholders
• Participate in planning, performance metrics, continuous improvement, communities of practice, and capability-building activities

Business Analyst III

Nurse

• Manage internal quality of care referrals and support quality initiatives under Clinical Services and CareOregon Quality Health Outcomes
• Complete Quality of Care reviews
• Work with the Director of Quality of Care to address quality and clinical issues in a timely and thorough manner
• Maintain accurate and complete documentation for quality of care files
• Use QNXT, SharePoint, and Smartsheet for quality monitoring
• Coordinate and facilitate risk-reduction strategies for quality and patient safety issues
• Collaborate with other departments to ensure quality of care processes work effectively
• Conduct annual and other trainings as needed
• Lead implementation and ongoing administration of health improvement programs
• Provide feedback to the Quality of Care Director and others
• Identify education and training programs for network providers, members, healthcare workers, and CareOregon staff supporting appeals and grievance processes
• Develop and monitor tracking systems for quality-of-care issue data, provider trends, and related clinical quality sources
• Provide clinical expertise in evaluating program outcomes and planning program activities
• Apply CMS, OAR, contract requirements, and other regulatory standards
• Apply and help develop and implement the Equity First approach
• Participate in contract review, peer review, and quality oversight committees
• Participate in provider site visits as needed

Registered Nurse – Quality of Care

Data Engineer

• Perform intermediate-level data warehouse architecture
• Create data models for moderate to advanced subjects
• Create ETL specifications to meet business data needs
• Develop and maintain design and operation documentation
• Analyze data sources and recommend solutions, including risks and mitigation
• Participate in long-term data warehouse and dashboard architecture planning
• Create and manage data warehouse and analytics architectures for solution development
• Propose requirements, standards, and best practices for data modeling, ETL specifications, and data warehouse development
• Review existing systems for compliance with established standards and to empower business operations
• Conduct product and vendor research and present recommendations to database developers and/or management
• Establish and maintain relationships with vendors and equipment suppliers, including installation and repair of services

IS Data Warehouse Architect, II

Pharmacist

• Provide customer service to CareOregon members, providers, pharmacies, and staff regarding pharmacy benefits and prescription needs
• Process pharmacy claims and resolve or triage claims adjudication issues
• Educate members, providers, pharmacies, and staff about formularies and pharmacy benefit policies
• Document customer service activities and maintain confidentiality under HIPAA
• Sort incoming faxes and maintain files
• Perform data entry in claims processing, document management, database, and spreadsheet systems
• Support pharmacy projects through education materials, letters, mailings, and reports
• Verify plan eligibility and benefits for drug coverage
• Review medication and eligibility history and load authorizations in claims adjudication platforms
• Assist with prior authorizations, formulary exceptions, and coverage determinations
• Perform prior authorization reviews with pharmacist oversight and notify stakeholders of decisions
• Intake, prepare, process, and communicate outcomes for pharmacy appeals and grievances
• Assist pharmacists, medical directors, and coordinators with appeals and grievances
• Support pharmacy benefit projects involving process improvements, cost savings, benefit changes, and outreach

Pharmacy Benefit Specialist II

• Support CareOregon members, providers, and pharmacies with pharmacy benefit and prescription needs under the major medical benefit
• Provide customer service and process pharmacy claims
• Respond to drug coverage inquiries and educate members, providers, pharmacies, and staff about formularies and pharmacy benefit policies
• Document customer service activities and maintain confidentiality under HIPAA
• Perform data entry into claims processing, document management, database, and spreadsheet systems
• Sort incoming faxes and maintain files
• Assist with pharmacy projects, education materials, letters, mailings, and reports
• Verify plan eligibility and drug coverage benefits
• Review medication and eligibility history and load authorizations into claims adjudication platforms
• Assist with prior authorization, formulary exception, and coverage determination processes
• Perform prior authorization reviews with pharmacist oversight and communicate decisions
• Process pharmacy appeals and grievances, gather documentation, prepare cases for review, and notify members and providers of outcomes
• Assist with process improvements, cost-saving initiatives, benefit implementations/changes, and outreach projects under pharmacist or operations supervisor supervision
• Work Monday through Friday

Security Engineer

• Implement and maintain corporate security and mature CareOregon’s security model
• Evaluate, architect, and implement information security policies and systems
• Design and maintain security technologies including firewalls, proxy systems, logging, and other security devices
• Provide advanced security technology knowledge and consult on projects
• Advise IS teams on security design best practices
• Execute ticket and service-request tasks from basic to advanced activities
• Analyze business needs and research and recommend solutions, risks, and mitigations
• Build, run, and review information security performance and event-anomaly reports
• Make system adjustments and identify security gaps based on findings
• Develop and maintain technology design and operations documentation
• Propose information security requirements and standards
• Review systems for compliance with established standards
• Develop and maintain information security policies
• Integrate network engineers into the development and management of security policies and systems
• Support disaster recovery and business continuity initiatives
• Develop, monitor, and maintain electronic data exchanges with outside entities
• Maintain service contracts and licensing and monitor vendor SLA adherence
• Escalate vendor issues as needed

RN Clinical Benefit Management Supervisor

Transportation Operations Coordinator

Business Analyst III

Registered Nurse – Quality of Care

IS Data Warehouse Architect, II

Pharmacy Benefit Specialist II

Pharmacy Benefit Specialist II

IS Security Engineer II