Supervisor Medicaid Services

Let’s do great things, together!

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.

Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

This position provides daily direction to staff by remaining current with mandated changes, system enhancements, administrative guidelines and contractual requirements. Performs and oversees encounter data processes and audits, claims/authorization audits and other specific audits as requested by Oregon Health Authority. Establishes operational goals, develops written procedures and provides direction to ensure contractual compliance and adherence to internal and OHA deliverable timelines. Works with providers and stakeholders as part of the Eastern Oregon Coordinated Care Organization (EOCCO) and OHSU Health IDS as well as Summit Health network to problem solve issues with claims, customer service and member access.  Creates and modifies existing Medicaid provider policies and materials in order to improve communications with plan and providers as well as development of strategic member communications and materials to ensure appropriate communication and engagement with Medicaid members.

This is a full-time on-site position based in Portland, Oregon. 

The pay range for this position is $74,334.50- $92,936.38 ​​​annually (depending on experience)

Please fill out an application on our company page, linked below, to be considered for this position.

• https://j.brt.mv/jb.do?reqGK=27731054&refresh=true

Benefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education:

• Masters Degree in Business Administration, Public Health or equivalent work experience.
• 2 – 4 years’ experience as a Medicaid Program Coordinator or equivalent experience consistently exceeding all levels of performance.  Prior claims processing and benefit/provider programming background.
• Working knowledge and understanding of OHP contracts, mandates and administrative policies affecting benefit and provider programming on internal computer systems.
• Ability to evaluate and analyze changes/updates to OHP and federal CMS rules and guidelines and how changes impact department.  Develop strategies to assist operational departments with implementing changes to ensure compliance.
• Demonstrated organizational, analytical and detail orientation skills in identifying programming needs and implementing an effective course of action.
• Excellent communication skills and the ability to act professionally with all internal and external customers.
• Ability to communication technical programming language to non-technical individuals both internally and externally.
• Ability to work well under pressure with frequent interruptions and shifting priorities in a complex and rapidly changing environment.
• Proficient in Microsoft Office applications.
• Maintain confidentiality and project a professional business presence and appearance.
• Ability to come in to work on time and on a daily basis.

Primary Functions:

• Oversight and Management of Staff:
  • Oversight of task and project completion as well as individual career development by establishing dedicated weekly check-ins with all staff.
  • Ensures cross training of all staff to align with short and long-term strategic goals of Medicaid operations.
  • Responsible for daily leadership to staff, including timekeeping, PTO processing, monitoring performance, conducting performance appraisals, counseling/mentoring, staff development, hiring and interviewing, etc.
  • Responsible for maintenance of departmental PTO, Scheduling and Travel policies.
• Medicaid Operations:
• • Management of EOCCO and OHSU Health Services Group Applications to ensure correct rates, rate groups and group structures are configured at the start of each new rate cycle and anytime changes are made mid-year; ensures that EOCCO and OHSU Health IDS receive accurate monthly premiums
  • Ensures OHA mandated changes are communicated to appropriate staff and implemented in a timely manner to improve overall performance errors for EOCCO and OHSU Health IDS.  Assists management with OHP contractual compliance.
  • Oversees and coordinates implementation of claims system updates, data base enhancements, network programming, and adding, changing, and maintaining annual updates.
  • Ensures OHP Medicaid policies, procedures, quality assurance, and turnaround standards are being followed throughout the company as well as by delegated entities. This includes performing reviews to verify accuracy, identifying corrective action and working to develop or modify existing policies to ensure compliance.
  • Responsible for development and oversight of activities, audits and material development as it relates to affiliated Medicare Advantage plans and communication to Full Benefit Dual Eligible members
  • Facilitates problem solving for providers, employees, and internal customers by answering operations related questions dealing with claims systems and contract interpretation related to benefits and administrative guidelines.
  • Remains apprised of any changes affecting OHP, communicates industry standards regarding OHP benefits administration, and provides direction accordingly.
  • Ensuring annual trainings meet all compliance and contractual requirements.
• Collaboration with Oregon Health Authority:
  • Participation and leadership role in completion and preparation for annual HSAG activities and audits.
  • Participating and engaging with OHA workgroups as it relates to CCO operations, encounter data, rate setting, and others as needed. Followed by dissemination and implementation of outlined changes.
  • Management and oversight of OHA TPA forms processing for Medicaid line of business.
  • Oversight of MCE Contact List and quarterly updates.
• Encounter Data and DMAP Enrollment:
  • Management oversight of encounter data processes, including but not limited to weekly pended claims counts, timely processing of encounter data, OHA encounter report processing and delegated vendor performance monitoring and compliance.
  • Responsible for identification of system limitations and updates needed to improve EOCCO and/or OHSU Health Services encounter data or other claims and configuration needs specific to data quality improvement and service request submission to address identified needs.
  • Management oversight of DMAP provider enrollment processes, abbreviated and expedited enrollments.
  • Management oversight of OHA provider revalidation project for EOCCO and OHSU HealthServices.
• Materials and documents:
  • Creates and updates required member communication materials, documents and materials including, but not limited to member handbook, member welcome packets, notification postcards and other documents as needed in collaboration with Marketing. Ensures that all materials are compliant with CCO contracts and consistent with Oregon Administrative Rules.
  • Ensures operational member communications and mailings are submitted to print & mail and sent to members with the timeframes indicated by OARs and CCO contract.
  • Analyzes material development process, web content and dissemination of information to ensure timely and compliant outcomes while implementing cost-savings strategies.
  • Introduces Medicaid operations to innovations in member engagement, communication, and health literacy to drive better health outcomes.
  • Oversight and monitoring of website content, utilization and updates for members and providers. Ensures health equity practices in the development and translation processes.
  • Ensures equitable practices in the development and translation processes.
• Innovations in Medicaid Operations & Member Engagement
  • Diversification and utilization of non-traditional member communication and engagement strategies.
  • Competitive market and public health research regarding member behavior change and healthcare decision empowerment strategies
  • Implementation of member technology platforms to create equitable and transparent access to information and resources.
  • Implementation and management of EOCCO social media utilization.
  • Vendor recruitment and implementation for communication platform and translation/transcription solutions.
• Cross-departmental collaboration:
  • Manages oversight and monitoring of website content, utilization and updates for members and providers.
  • Fostering working relationships with Membership accounting, Medical provider relations, customer service marketing and ODS community dental staff. Ensuring that these business areas are appraised of changes and updates to Medicaid operations, policy changes, provider or member communications as well as cross-collaborating on overlapping initiatives.

Working Conditions:

• Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Occasional travel to off-site meetings, which may include overnight stays. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business need.

Contact with Others

• Internally with, Configuration, Marketing, Print & Mail, Medical Professional Relations, EDI, Actuarial, Customer Service, Claims, Medicare, Pharmacy, HealthCare Services, Membership Accounting and IT. 
• Externally with GOBHI staff and leadership, OHSU Health IDS staff and leadership, OHA stakeholders (including encounter data, quality assurance and communications) and network providers and clinic staff.

Together, we can be more. We can be better.
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Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. 

For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our humanresources@modahealth.com email.