**Location : **Remote: This position has the possibility of being 100% remote.

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.

Department: Health Plan Operations FLSA Status: Exempt

Reports To: Health Plan Operations Manager Physical Strength: Light (L)

Learn more about Yamhill Community Care: click here

Summary

The Health Plan Operations Specialist is instrumental in the administration of health plan benefits for the Yamhill Community Care (YCCO) Oregon Health Plan (OHP) members. This position is responsible for performing department projects, operations, and compliance activities including all aspects of the member communication process, and works to monitor internal system performance, and the system performance of managed care subcontractors to ensure appropriate administration of the health plan benefits on an ongoing basis. This position may assist in conducting 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.

Essential Duties

1. Performs ongoing benefit administration activities with staff, subcontractors, and providers, as needed to address coverage and benefit programs, questions, and issues identified.
2. Serves as primary contact for subcontractors and YCCO staff for system inquiries and updates to plan member benefits, communication materials review, and facilitates gaining internal and external approvals as required.
3. Implements internal department and subcontractor oversight and system improvements to health plan programs and services.

Job Duties

Daily Plan Operations

• Works independently to interpret and apply complex regulations, laws, and guidelines and to evaluate internal departments and 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.
• Develops, revises, and maintains policies, procedures, tools, and/or processes to meet regulatory requirements in all health plan operations.
• Maintains all documentation to support evidence of meeting member communication requirements including material creation, review criteria, and gaining OHA approval.
• Provides technical assistance, as needed, to subcontractors regarding OHP benefits and member materials and documents all communications with subcontractors.
• Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, EQRO) as requested.

Subcontractor & Provider Compliance

• Ensures delegation expectations and standards are clearly understood by subcontractors.
• Meets with and remains in contact with subcontractors to ensure appropriate benefit administration expectations and standards are clearly understood.
• Works in coordination with YCCO department and teams – Health Plan Operations, Quality Assurance Team, Compliance Team including the Chief Medical Officer (CMO), to meet appropriate health plan benefit administration.
• Provides technical assistance to subcontractors, as needed, regarding member materials and health plan benefits.
• Assist with audits of delegated functions using audit tools.

Process 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 to assist with audits; 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.
• Performs 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 operational 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 reports.
• Ability to interpret regulatory and contractual obligations and translate into operations process and procedures required of Community Care Organizations (CCO).
• 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 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.
• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
• Ability to communicate 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 responsibility.

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:

• Two (2) years of experience in healthcare, nonprofit, and/or public health programs.
• Experience developing and administering program plans, timelines, and deliverables, including data and reporting.

OR:

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

Preferred:

• Bachelor’s degree or training in public administration, quality assurance and/or community health operations.
• Experience working with diverse stakeholders and business partners.

Certificates, Licenses, and/or Registrations

This position does not require any certificates, licenses, or registrations.

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.