Job Title Delegation and Quality Oversight Manager Exemption Status Exempt Department Health Share of Oregon Manager Title Director, Compliance and Quality Oversight Direct Reports Delegation and Quality Oversight Specialists and Coordinators Requisition # 24509 Pay and Benefits Estimated hiring range $109,251 - $133,529 / year, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits Posting Notes This is a hybrid position that will require you to go into the downtown Portland office once a month for meetings. Job Summary The Delegation and Quality Oversight Manager plays a lead role overseeing the work of the Delegation and Quality Oversight (DQO) team. The work of that team includes delegation oversight of subcontracted entities, fraud waste and abuse prevention planning and investigations, grievances, hearings and appeals, corporate risk assessment and compliance education and technical assistance. This position develops, designs, implements, and oversees policies and processes to assess compliance with delegated functions and assurance of provision of quality services to Health Share members. This position is responsible for the collaboration between Health Share and subcontracted entity staff to ensure that all delegated functions and quality oversight activities are meeting federal, state and Health Share contracted and regulatory requirements. Essential Responsibilities Compliance and Quality Oversight Operations + Oversee compliance, External Quality Review, and audits of subcontracted organizations from pre-audit notifications through to completion and oversight of required plans of correction. + Develop and implement policies and procedures that meet the Oregon Health Authority contractual requirements, including all audits by external parties. + Oversee the daily operations of Health Share’s Grievance System program, including tracking, documentation, collection, file maintenance, reporting and resolution of the hearings, appeals and grievances processes. + Develop and lead Health Share’s delegation auditing and compliance monitoring activities to address specific healthcare compliance risks utilizing the Seven Elements of an Effective Compliance program. + Maintain and revise processes to prevent, detect, and correct any evidence of internal control deficiencies, duplication of efforts, or fraud, waste, and abuse including monitoring of the Compliance Hotline. + Organize, prioritize, and assign work; monitor status of work in progress and confer with staff to assist with complex/problem situations and provide technical expertise. + Develop and implement compliance and quality oversight trainings for internal and external staff. + Act as an expert resource for Health Share staff and delegated entities, providing consultation as needed. + Develop proactive communication strategies for all levels of the organization and external stakeholders. + Organize and conduct Compliance Workgroup meetings related to compliance and regulatory expectations. + Support the Director of Compliance and Quality Oversight with the Compliance, fraud, waste, and abuse and Enterprise Risk Management process. + Manage contracts, deliverables, timelines and expectations with partners and project vendor(s). + Oversee the process of tracking, completion, and timely submission of required reports to Health Share by subcontracted organizations. + Identify, evaluate, and prioritize delegation oversight compliance risk through an annual risk assessment process that supports the development of an internal annual delegation oversight compliance audit plan. + Collaborate with information technology and health analytics in the development of a data tracking process as needed. + Ensure alignment of project outcomes with the CCO’s commitment to racial equity and the goals of the CCO’s Community Health Improvement Plan. + Work collaboratively to analyze project needs, identify solutions, and inform leadership and health system partners of strategic opportunities. + Develop clear pathways for communication and escalating project barriers, as appropriate. + Work with technical experts to optimize data analysis to inform policies and procedures required for the organization to execute on contractual responsibilities. + Facilitate consensus and collaboration among diverse stakeholders and partners using influencing skills when required and always with diplomacy and discretion. Employee Supervision + Manage team(s) and recommends team direction and goals in alignment with the organizational mission, vision, and values. + Identify work and staffing needs to meet work expectations; recruits and hires, using an equity, diversity, and inclusion lens. + Plan, organize, schedule, and monitor work; ensures employees have information and resources to meet job expectations. + Lead the development, communication, and oversight of team and individual goals; ensures goals, expectations, and standards are clearly understood by staff. + Train, supervise, motivate, and coach employees; provides support toward employee development. + Incorporate equity tools into people leadership, planning, operations, evaluation, and decision making. + Ensure team adheres to department and organizational standards, policies, and procedures. + Evaluate employee performance and provides regular feedback to support success; recognizes strong performance and addresses performance gaps and accountability (corrective action). + Perform supervisory tasks in collaboration with Human Resources as needed. Organizational Responsibilities + Perform work in alignment with the organization’s mission, vision, and values. + Support the organization’s commitment to equity, diversity, and inclusion by fostering a culture of open mindedness, cultural awareness, compassion, and respect for all individuals. + Strive to meet annual business goals in support the organization’s strategic goals. + Adhere to the organization’s policies, procedures, and other relevant compliance needs. + Perform other duties as needed. Knowledge, Skills and Abilities Required Knowledge + Knowledge of federal, state, and national health care compliance regulations related to Medicaid (Title XIX of the Social Security Act) + Knowledge of principles, practices, procedures, and professional standards associated with quality assurance program management, utilization review and techniques for evaluation of program effectiveness + Knowledge and experience with delegation oversight of managed health care operations + Knowledge of database structure and functionality Core Skills and Abilities + Competency with computer software programs (i.e., MS Outlook, Word, Excel, and PowerPoint) + Ability to research, understand, interpret, and communicate federal and state requirements, including the Code of Federal Regulations, Oregon Revised Statutes and Administrative Rules, HIPAA, Fraud, Waste, and Abuse laws, False Claims Act, Anti-Kickback laws, etc. + Understanding of the audit process, including the development of audit plans (objectives, methodology, sampling, testing) and preparation of work papers and documentary evidence in accordance with professional auditing standards + Ability to set goals independently and prioritize work to balance competing deadlines in a professional manner, while managing multiple tasks + Excellent engagement and partnership skills, including written and verbal communication with a broad array of stakeholders, including public presentations of data and complex processes as needed + People leadership skills, including the ability to coach, develop, and manage staff + Ability to work in an environment with diverse individuals and groups + Ability to manage multiple complex tasks and projects and delegate work effectively + Ability to work well under pressure in a complex and rapidly changing environment + Strong project management and process improvement skills, including deliverables oversight, communication, and barrier identification + Well-developed organizational, problem-solving, and time-management skills + Ability to gather, compile and organize data + Ability to build and maintain effective relationships and collaboration + Ability to effectively review and organize systems and workflows + Ability to be self-directed and work independently with minimal supervision as needed + Ability to manage project scope and timelines effectively + Ability to assess a situation and seek or determine appropriate resolution Physical Skills and Abilities + Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day + Ability to hear and speak clearly for at least 3-6 hours/day Cognitive Skills and Abilities + Adept at utilizing various approaches to achieve favorable outcomes, manage change, and influence others + Ability to work effectively with diverse individuals and groups + Ability to learn, focus, understand, and evaluate information and determine appropriate actions + Ability to focus on and comprehend information and learn new skills and abilities + Ability to accept managerial direction and feedback and tolerate and manage stress Experience and/or Education Required: + Minimum 5 years’ experience in healthcare, compliance, and/or quality assurance, including minimum 3 years in Medicaid/Medicare compliance, quality assurance and/or delegation oversight + Minimum 2 years’ experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of Health Share’s Aspiring Leaders Program Preferred: + Certification in Healthcare Quality (CPHQ) or Healthcare Compliance (CHC) Working Conditions Primary Work Environment: ☒ Indoor/Office ( ☐ Remote or ☒ Hybrid) ☐ Member Facing ☐ Patient Facing ☐ Facilities/Security Other Work Environment(s): ☐ Indoor/Office ☐ Member Facing ☐ Patient Facing ☐ Facilities/Security ☐ Outdoor Exposure Hazards: General office hazards, which most commonly include potential physical and ergonomic hazards, such as falls, cuts, repetitive strains, accidents, etc. Equipment: General office equipment Travel: This position may include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used 2121 SW Broadway #200, Portland, OR 97201 | 888-519-3845 | TTY 711 | healthshareoregon.org #Li-Hybrid Health Share is an equal opportunity employer and employs personnel without regard to age, citizenship, color, creed, physical or mental disability, economic status, education, ethnicity, family responsibilities, gender identity and expression, genetic information, health status including HIV status, height, housing status, marital status, matriculation, national origin, physical appearance, race, religion, political affiliation, pregnancy, sex, sexual orientation, union membership, veteran status or other unlawful factors, with respect to recruiting, hiring, job assignment, promotion, discipline, discharge, compensation, training and other terms, conditions and privileges of employment and contracting. Health Share is committed to creating a diverse staff made of people who are dedicated, optimistic and committed to health equity from all segments of the greater Portland Region, and we encourage people of color, people with disabilities, LGBTQ+ people, women and nonbinary people, and Veterans to apply for consideration. Visa sponsorship is not available at this time.