PacificSource Health Plans

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Provider Network Delegation Oversight Program Manager serves as one of PacificSource’s Medicaid Non-emergent Medical Transportation (NEMT) benefits subject matter experts with primary responsibility to carry out routine oversight of functions delegated to NEMT brokerages and provide key support to the overall administration of PacificSource’s Medicaid NEMT benefit. This role is also responsible for carrying out routine oversight of functions delegated to Kaiser Permanente. Responsibilities include participating in the overall management of both Kaiser Permanente and NEMT brokerage performance, supporting the Provider Network Contracting Team as needed, participating with delegate relationship stewardship, representing and advocating for PacificSource’s NEMT interests at the local and state level, and facilitating and/or participating with regulatory compliance and alignment activities.

Essential Responsibilities:

• Oversee and steward PacificSource’s routine oversight program with NEMT brokerages and Kaiser Permanente. Regularly work and communicate with NEMT brokerage and Kaiser Permanente representatives and leaders. Organize, lead, and or participate with regularly occurring meetings with NEMT brokerages and Kaiser Permanente.
• Support NEMT brokerage and Kaiser Permanente contracting activities to ensure compliance with all applicable performance and monitoring requirements. Consult and collaborate with team leadership, Provider Network Contracting Team, legal and line of business leaders as appropriate.
• Conduct routine NEMT and Kaiser Permanente oversight activities to ensure compliance with federal and state requirements, PacificSource’s contract with the Oregon Health Authority, and stipulations within PacificSource’s contracts with Kaiser Permanente and NEMT brokerages. Evaluate NEMT brokerage compliance with applicable regulations and contract requirements. Carry out corrective actions including implementing formal corrective action plans with delegates when required.
• Collaborate with the Compliance Department when needed on the completion of annual and periodic delegate quality and compliance audits and other activities as necessary.
• Participate with, recommend and/or promote utilization, network, and capacity oversight and improvement activities. Provide support as needed to other PacificSource teams also conducting oversight activities.
• Lead and facilitate annual updates to Oregon Health Authority-required NEMT policies and rider guides. Ensure NEMT brokerages adopt and implement required policies and call center scripts.
• As needed, collaborate with the Delegation Oversight Team and Compliance Department on the completion of annual and periodic delegate quality and compliance audits; help compile and organize materials; draft written responses; present oral responses to auditors during on-site activities; and plan and draft written corrective actions to address audit findings.
• Support efforts to fulfill Oregon Health Authority (OHA) contractual obligations of Coordinated Care Organizations (CCOs).
• In collaboration with Provider Network Contracting Team, provide support as needed with NEMT brokerage and Kaiser Permanente value-based payment (VBP) arrangements that tie reimbursement to performance with key metrics.
• Provide recommendations to leadership regarding participation in NEMT and Kaiser Permanente strategy development.
• Collaborate and partner with team leadership and other various PacificSource departments and teams on quality improvement, member concerns, and the like.
• Participate with cross-department and external innovation efforts, QI, transformation, and strategy projects, driver and provider workforce development, business and policy strategy planning, and community or state interests.
• Stay up to date with applicable rules, contracts, policy changes, quality innovation, best practice development, and industry and benefit trends. In partnership with line of business leaders, evaluate, determine and/or advise, and carry out strategic courses of action.
• Represent PacificSource’s interests by participating with applicable forums; advisory, industry, and advocacy groups; and policy and/or rule-making committees.

Supporting Responsibilities:

• Collaborate as appropriate with the Quality team, Population Health team, and Provider Relations teams as supporting business partner with applicable Quality Incentive Metrics (QIM) performance and other quality initiatives.
• Participate when requested with state Medicaid contract RFPs, and other types of bid processes.
• Participate as needed with regional Health Council and community stakeholder forums.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum five (5) years of experience in the health care, managed care, or the NEMT industry required. Experience with Medicaid programs and managed care strongly preferred.

Education, Certificates, Licenses: Bachelor’s degree in business, health care administration, or a related field, or equivalent years of additional relevant experience in lieu of degree. Master’s degree preferred.

Knowledge: Experience with carrying out systems for monitoring health care organization performance with Medicaid regulations, requirements, and contract stipulations. Experience designing and implementing quality improvement and/or corrective action performance improvement plans or initiatives. Experience engaging community stakeholders and conducting stakeholder/provider meetings. Experience leading and contributing to cross functional teams to initiate work, problem solve, develop and execute plans, and complete work requirements. Knowledge of State Medicaid programs and health plans, the Oregon Health Plan, Coordinated Care Organizations, and managed care provider or subcontractor contracting. NEMT brokerage and driver network operations knowledge preferred. Excellent organization and interpersonal skills. Demonstrated successful communication skills, including technical writing, public presentation, and meeting facilitation. Strong analytical and problem-solving skills. Demonstrated skills with the following software: Microsoft Word, PowerPoint, and Excel.

Competencies

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Skills:

Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.