Providence Health & Services Supervisor - Medical Management in Beaverton, Oregon
Providence is calling a Supervisor-Care Management to Providence Health Plans in Beaverton, OR.
In this position you will have the following responsibilities:
Conduct forensic claims auditing to support appeals, both contractual and regulatory.
Oversee the daily activities and processes of the transplant prior authorization, pre-payment claims audit and appeals teams
Perform the six essential activities of case management: assessment, coordination, planning, monitoring, implementation and evaluation in multiple environments.
Perform case management of chronic and catastrophic cases to effectively manage services, benefits, costs and quality following policies and procedures of the Utilization Management Program.
Provide case management for specialty programs as required by commercial and government contracts or product design.
Develop and maintain positive relationships with providers and facilities to facilitate case management; maintain knowledge in subject matter and enhance Health Plan expertise in the area of case management.
Track and report case management activities, savings and outcomes as appropriate for the individual program and as required, supporting the Utilization Management Program.
Screen members identified through Health Risk assessments as high cost/complex for potential case management.
Maintain a thorough knowledge of utilization management and cost containment strategies, member and providers contracts, utilization management program, imaging and workflow systems and personal computer applications.
Identify internal and external customers, determine customer needs and satisfy those needs.
Assure that all responsibilities are performed consistent with the deliberate plans of the organization; maintain a sensitive, caring, and safe environment for customers, co-workers, providers, and others while operating within the limits of approved budgets.
Identify quality of care issues forwarding them to Quality Management for review.
Required qualifications for this position include:
Graduation from an accredited school of nursing or graduation from an accredited equivalent clinical program (i.e.: Council on Social Work Education). Applicable work experience may be substituted for some education.
5 years of clinical experience.
Clinical license in good standing in the state of Oregon.
Experience with managed care services including population health initiatives, Affordable Care Act, Coordinated Care Organizations, Accountable Care Organizations, Medicare and Medicaid regulations.
Demonstrated leadership that cultivates others to exceed and develop.
Strong interpersonal skills at all levels from team members to senior level leadership.
Solution driven using detailed quantitative analysis and process expertise.
Experience with development of innovative and focused partnerships and programs which challenge the norm to support an ever changing healthcare environment.
Experience in cost stewardship using Lean principles or other means which increase effectiveness and cut waste.
Current licensed driver.
Preferred qualifications for this position include:
Bachelor Degree in Nursing or other Clinical degree.
Previous supervisory or lead experience
LCSW, if applicable.
About Providence in Oregon
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple,
"Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer a full comprehensive range of benefits - see our website for details
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Supervisory / Management
Req ID: 189172