Claims Manager --------------------------------------------------------------- Job Summary The Claims Manager is responsible for leading best practices and daily operations of the Claims department that spans multiple lines of business and types of claims. Responsibilities include ensuring oversight of claims management, vendor relationships, and the implementation of technological best practices to improve the department’s capabilities to meet the needs of members. The position provides leadership and development opportunities for the Claims team and ensures that CareOregon standards and all applicable contract requirements are met or exceeded. Estimated Hiring Range: $90,225.00 - $110,275.00 Bonus Target: Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. --------------------------------------------------------------- Essential Responsibilities Manage the operations of the Claims department to ensure the department meets productivity and quality standards and promotes efficiencies through automation and cost containment efforts. Ensure strict adherence to Medicare, Medicaid, MSA, ASO and Plan contract requirements. Collaborate with IS, Audit and Compliance, Provider Services, Medical Management and Line of Business leaders and staff to ensure effective integration across teams. Partner with CareOregon departments, lines of business, programs, providers and partners. Ensure the timely and accurate processing of claims and adjustments. Support payment integrity program initiatives. Promote CareOregon values, particularly in the areas of customer service, change management, leadership, performance levels and results orientation. Champion organizational goals related to Medicare Star Ratings, Coordinated Care Organization (CCO) metrics, compliance and other initiatives. Recommend and implement changes in guidelines, procedures and policies to comply with changes in federal regulatory requirements or improve efficiencies and performance. Implement claims strategies related to Medicare/Medicaid and any applicable line of business. Analyze available information to find opportunities for operational improvements and ways to help employees perform at their best. Provide accountability for service level goals and performance guarantees. Serve as the claims liaison for internal and external audits and reviews. Manage vendor relationships as they relate to functions of the department. Develop and communicate weekly inventory of Service Level Agreement (SLA) misses along with root cause analyses and mitigation plans. Develop, manage and report on any inventory backlog reduction plans. Participate in and lead projects related to claims processing as needed. Develop presentations and present claims-related information as needed. Employee Supervision Direct teams and establish team direction and goals in alignment with the organizational mission, vision, and values. Identify work and staffing models; recruits, hires, and oversees a team to meet work needs, using an equity, diversity, and inclusion lens. Identify department priorities; ensure employees have information and resources to meet job expectations. Lead the development, communication, and oversight of team and individual goals; ensures goals, expectations, and standards are clearly understood by staff. Manage, coach, motivate, and guide employees; promote employee development. Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, budgeting, resource allocation, 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 claims administration 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 Supervisory experience within claims administration or a related field (e.g., provider relations, configuration, etc.) Knowledge, Skills and Abilities Required Knowledge Strong understanding of state and federal regulations that impact operations and ability to properly respond Skills and Abilities Proficient in claims system software (e.g., QNXT or similar claim processing systems) Proficient in Microsoft Office products (Outlook, Word, Excel, etc.) Management and leadership skills, including the ability to drive results through others Skill in negotiation and ability to build consensus Ability to mentor and promote the growth of individuals Strong analytical and problem-solving skills Strong organizational skills Excellent spoken and written communication skills Excellent interpersonal skills Strong presentation skills Ability to diplomatically deescalate difficult situations and expertly resolve high exposure complaints Ability to work well under pressure in a complex and rapidly changing environment Ability to positively and professionally represent the organization to internal and external customers, business partners and staff 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, and perform repetitive finger and wrist movement for at least 6 hours/day Ability to hear and speak clearly for at least 3-6 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. Work Location: Work from home We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, 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.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information. We are an equal opportunity employer CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization. CareOregon is a nonprofit, mission-driven health plan, focused on providing care to low-income Oregonians. The CareOregon family includes Columbia Pacific CCO, Jackson Care Connect, Housecall Providers and our work as part of Health Share of Oregon. We also support recruitment for The Collaborative. Our mission is to inspire and partner to create quality and equity in individual and community health. Our vision is healthy communities for all individuals, regardless of income or social factors. Making Healthcare Work for Absolutely Everyone. Let's connect! Add your resume to our Talent Community to stay up to date with relevant career opportunities. Learn more about our benefits and joining CareOregon Click here for more information about jobs at Housecall Providers, part of the CareOregon family. 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. Veterans CareOregon greatly encourages military veterans to apply. CareOregon is a major sponsor of the annual Portland Veterans Stand Down and hiring fair. Ranked #8 in the Health Care Category. Read more about the culture at CareOregon