Location: Hybrid. Most of the positions at YCCO are hybrid, meaning they have the flexibility to work both remotely and/or in-person at YCCO's office in McMinnville, OR.

COVID-19 Update for Prospective Employees: YCCO is no longer requiring COVID-19 vaccination for employees.

Department: Heath Plan Operations FLSA Status: Exempt

Reports To: Health Plan Operations Sr. Director Physical Strength: Light (L)

Summary

This position is responsible for providing programmatic administration of department projects, operations, and compliance activities; is instrumental in tracking and monitoring internal system performance and of managed care subcontractors on an ongoing basis. This position conducts formal reviews of entities compliance, identifies areas for improvement, and works collaboratively to resolve issues in accordance with Oregon Health Authority (OHA) contracts by performing the following duties.

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Essential Duties

Job Duties

Subcontractor & Provider Compliance

• Conducts pre-delegation and annual reviews for new and existing subcontractors for compliance in the following areas: Utilization Management, Authorization, Clinical Guidelines, Appeals, and Managed Physical, Behavioral and Dental Health Operations.
• Ensures delegation expectations and standards are clearly understood by subcontractors.
• Meets with and remains in contact with subcontractors to ensure delegation expectations and standards are clearly understood.
• Monitors and evaluates subcontractors to ensure performance of delegated activities in accordance with the agreement and regulatory requirements.
• Works in coordination with YCCO department and teams – Health Plan Operations, Quality Assurance Team, Compliance Team including the Chief Medical Officer (CMO), to monitor and analyze outcomes to ensure goals, objectives, and regulatory requirements are met.
• Provides technical assistance and training to subcontractors, as needed, regarding compliance intervention strategies.
• Coordinates third party liability and personal injury lien processes with YCCO vendor.
• Performs oversight of subcontractor credentialing activities.

Quality Oversight & Compliance

• Works independently to interpret and apply complex regulations, laws, and guidelines and to evaluate subcontractors for compliance with contractual and regulatory requirements.
• Develops and implements effective operational processes to prevent, detect, and correct any evidence of internal control deficiencies and duplication of efforts.
• Performs oversight activities to investigate and monitor compliance with State and Federal laws and regulations, Medicare and Medicaid regulations, billing guidelines and HIPAA regulations, as needed, and write reports and create trend analysis on data received and reviewed.
• Develops, revises, and maintains oversight tools, processes and follow-up actions as necessary to comply with State and Federal regulatory requirements.
• Maintains all documentation to support evidence of compliance with all delegation requirements.
• Provides technical assistance, as needed, regarding compliance intervention strategies.
• Appropriately prepares and documents oversight activities including follow-up actions.
• Conducts audits of delegated functions using audit tools and develops corrective action plans to address any identified issues.
• Ensures the subcontractor performs the delegated activities in accordance with the agreement and regulatory requirements.
• Participates in annual risk assessment process to identify and collect organizational risk and supports the development of the annual audit plan.
• Actively participates in YCCO compliance and operational quality meetings as identified.
• Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, EQRO) as requested.

Analysis & Reporting

• Collects and summarizes performance data, identifies opportunities for improvement, and presents findings to leadership.
• Supports the development of policies and procedures that comply with State regulations and/or accrediting body requirements as applicable.
• Reviews performance dashboards and subcontractor reports; identifies deficiencies and notifies key department leaders for follow-up.
• Tracks and monitors incident response to identified issues and escalation to key department(s) and staff.

Process Improvement

• Contributes to the ongoing review of data relevant to the functional areas of quality assurance operations and compliance.
• Contributes to identifying training opportunities and other changes that result in improvement
• Participates in internal, external and State-lead workgroup meetings related to regulatory expectations.
• Assists with projects related to system and clinical quality improvement efforts and care coordination.

Essential Department & Organizational Functions

• Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.
• Participates in the preparation and submission of regulatory and contract required deliverables.
• Works closely with other YCCO departments, including Health Plan Operations and Compliance for auditing purposes, including the External Quality Review (EQR), as needed.
• Proposes and implements process improvements.
• Meets deadlines for completion of assigned responsibilities and projects.
• Maintains agreed upon work schedule with punctual, regular, and predictable attendance.
• Demonstrates cooperation and teamwork using a professional and respectful demeanor.
• Provides cross-training on specific job responsibilities.
• Meets identified goals that contribute to departmental goals.
• Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.
• Respectfully takes direction from Supervisor.
• Other duties as assigned.

Knowledge, Skills, & Abilities

• Understanding of managed care principles for both Medicaid and Medicare.
• Knowledge of network health service delivery systems.
• Ability to identify best practices as they relate to delegated functions.
• Ability to communicate both professionally and effectively verbally and in writing.
• Ability to analyze general, statistical, and technical reports, and synthesize data from diverse sources for writing audit reports.
• Ability to interpret regulatory and contractual obligations required of CCOs.
• Understanding of State and Federally managed care program requirements including Oregon Health Plan (OHP) and Medicare.
• Knowledge of auditing and monitoring processes.
• Ability to perform independent analysis, critical thinking, and sound clinical judgment.
• Ability to coordinate and communicate with a variety of contract parties and stakeholders.
• Be self-directing with minimal supervision.
• Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a matrix or shared resources across departments work model.
• Possess a high degree of initiative and motivation along with the ability to effectively collaborate and plan with others.
• Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.
• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
• Ability to communicate both professionally and effectively in all forms of communication.
• Ability to work in an environment with diverse individuals and groups.
• Ability to remain flexible, positive, and adaptable.
• Ability to work across the YCCO region and to work remotely, as needed.

Supervisory Responsibilities

This position has no supervisory responsibilities.

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:

• Minimum of four (4) years of experience in compliance and auditing, including regular exposure to quality expectations, policies, and standards.

OR:

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

Preferred:

• Master’s or Bachelor’s degree in health administration, public health, or health related field.
• Experience with managed care processes, operations, and auditing of clinical programs.
• Experience administering the Oregon Health Plan (OHP) (Medicaid).
• Experience administering the Centers for Medicare and Medicaid Services (CMS) (Medicare) benefits.

Certificates, Licenses and/or Registrations

Preferred:

• Certified Professional Coder
• Certified Professional Biller
• Certified Professional Medical Auditor
• Similar/Equivalent Certification

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.