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CareOregon

Managed care with social support programs.

Clinical Operations Manager - Medicare

Business OperationsPosted on Nov 11
Full-timeOregon, USA

About the Job

Requirements

  • A minimum of 5 years of experience in healthcare operations, care management, population health, or quality improvement is required.
  • A master's degree in Healthcare Administration, Public Health, Social Work, or a related healthcare field is required.
  • Advanced knowledge of Medicare Advantage and D-SNP operations is required.
  • Advanced knowledge of CMS Model of Care requirements is required.
  • Advanced knowledge of care management and care coordination practices is required.
  • Knowledge of population health management principles is required.
  • Knowledge of quality improvement methodologies is required.
  • Advanced knowledge of healthcare regulatory and compliance standards is required.
  • Advanced knowledge of health equity and social determinants of health is required.
  • Knowledge of healthcare operational metrics and reporting is required.
  • Operational planning and execution skills are required.
  • Project and program management skills are required.
  • Process improvement and workflow optimization skills are required.
  • Data analysis and performance measurement skills are required.
  • Audit preparation and compliance management skills are required.
  • Change management skills are required.
  • Reading, oral, and written communication skills are required.
  • The ability to collaborate effectively with leadership, staff, and other stakeholders is required.
  • The ability to use care management platforms and clinical documentation systems is required.
  • The ability to use Microsoft Excel, Power BI, Tableau, or similar reporting tools is required.
  • The ability to develop Medicare reporting requirements and performance dashboards is required.
  • The ability to work effectively with diverse individuals and groups is required.
  • The ability to learn, focus, understand, and evaluate information and determine appropriate actions is required.
  • The ability to accept direction and feedback and tolerate and manage stress is required.
  • The ability to see, read, and perform repetitive finger and wrist movements for at least 6 hours per day is required.
  • The ability to hear and speak clearly for at least 3–6 hours per day is required.

Responsibilities

  • Manage daily operations supporting the D-SNP Model of Care and care management programs.
  • Oversee execution of clinical workflows related to member assessments, care planning, care coordination, and care transitions.
  • Ensure consistency and standardization of clinical operational processes across teams.
  • Support implementation and ongoing administration of the CMS-approved Model of Care.
  • Lead operational improvement initiatives, workflow optimization efforts, and technology enhancements to improve efficiency, resource utilization, program effectiveness, and member outcomes.
  • Monitor staffing models, productivity measures, and workload distribution.
  • Monitor, analyze, and report operational performance metrics to ensure compliance with contractual, regulatory, and organizational requirements and achievement of program goals.
  • Partner with Quality Improvement teams to improve STAR ratings measures, HEDIS performance, care management measures, member satisfaction outcomes, and health equity initiatives.
  • Lead resolution of operational issues, performance gaps, and audit findings through corrective action planning, stakeholder collaboration, and escalation management.
  • Develop and maintain operational dashboards and reports.
  • Assist in developing and maintaining Model of Care policies, procedures, workflows, and training materials.
  • Analyze clinical and operational data to identify trends, opportunities, and performance risks.
  • Present operational results and recommendations to leadership teams.
  • Partner with analytics teams to support population stratification and intervention targeting efforts.
  • Coordinate audit readiness and support for CMS, NCQA, state regulatory, internal, and Model of Care evaluations, including gap remediation, documentation review, and corrective action planning.
  • Monitor compliance with key Model of Care requirements, including Health Risk Assessments, Individualized Care Plans, Interdisciplinary Care Team activities, care transition management, and Special Needs Population interventions.
  • Monitor changes in regulatory guidance and support implementation of new requirements.
  • Maintain accurate records and reporting to support compliance activities.
  • Serve as a liaison between clinical operations and key vendor partners.
  • Coordinate activities across Care Management, Population Health, Quality Improvement, Pharmacy, Behavioral Health, Network Management, Provider Relations, Compliance, and Medicaid Operations.
  • Support provider engagement efforts related to care coordination and Model of Care requirements.
  • Participate in organizational committees and governance structures supporting D-SNP operations.
  • Manage the team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
  • Identify work and staffing needs to meet expectations; recruit and hire using an equity, diversity, and inclusion lens.
  • Plan, organize, schedule, and monitor work, and ensure employees have the information and resources to meet job expectations.
  • Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
  • Train, supervise, motivate, and coach employees, and support employee development.
  • Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision-making.
  • Ensure the team adheres to department and organizational standards, policies, and procedures.
  • Evaluate employee performance and provide regular feedback; recognize strong performance and address performance gaps and accountability through corrective action.
  • Perform supervisory tasks in collaboration with People and Culture as needed.

Desired Qualifications

  • A Registered Nurse credential, Certified Case Manager credential, or Project Management Professional credential is preferred.
  • A Certified Professional in Healthcare Quality credential is preferred.
  • Three years of Medicare Advantage, Medicaid Managed Care, SNP, or D-SNP experience is preferred.
  • At least 2 years of supervisory experience, or at least 1 year of supervisory experience with completion of CareOregon’s Aspiring Leaders Program, is preferred.

About the Company

CareOregon

Managed care with social support programs.

CareOregon runs a health plan in Oregon that helps hundreds of thousands of people get medical care and also funds programs that address social needs like housing, healthy food, and job training. Its product works by providing health coverage and access to services through a Member-focused program, while also financing community initiatives that support overall well-being. What sets CareOregon apart is its emphasis on social determinants of health and the wider “CareOregon Effect”—improving people’s lives beyond medical care and focusing on community impact. The company’s goal is to improve health outcomes for its members and strengthen the broader community by investing in multiple services that support stable housing, nutrition, work skills, and more.

Company size
501-1,000
Company stage
Not listed
Total funding
Not listed
Headquarters
Portland, OR
Founded
1994

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