Delegation and Quality Oversight Specialist

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.

Job Title	Delegation and Quality Oversight Specialist
Exemption Status	Exempt
Department	Delegation and Quality Oversight
Manager Title	Delegation and Quality Oversight Manager
Direct Reports	n/a
Requisition #	24865
Pay and Benefits	Estimated hiring range $73,035 - $89,265, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits
Posting Notes	This is a fully remote role, but you must reside in one of the listed 9 states.

Job Summary

The Delegation and Quality Oversight (DQO) Specialist is responsible for monitoring performance of delegated entities, providing oversight of delegated functions including care and utilization management, quality assurance and performance improvement programs, and helping to ensure program integrity.

Essential Responsibilities

• Performs audits and conducts ongoing monitoring of delegated entities to ensure compliance with federal and state laws, Medicaid regulations, Health Share contracts and related policies and procedures.
• Reviews materials submitted, including policies, sample files, program documentation and other materials relevant to the audit protocol.
• Conducts analysis of data relevant to the functional areas of the audit; identifies opportunities for improvement.
• Writes reports summarizing findings; monitors plans of correction submitted in response to findings.
• Presents or reports findings and recommendations to the Delegation Oversight Committee.
• Participates in the development of evaluation tools that produce quantitative and qualitative data on performance of delegated entities.
• Reviews grievance system analyses submitted by delegated entities and ensures grievance systems are managed in accordance with Oregon Administrative Rules.
• Provides updates to manager on quality and delegation oversight responsibilities and recommends program improvements.
• Participates in an annual risk assessment that identifies and evaluates delegation risk as part of the Enterprise Risk Management program.
• Provides back-up support in representing Health Share at contested case hearings and administrative reviews, ensuring that hearings and reviews are managed in accordance with Oregon Administrative Rules.
• Convenes partners and stakeholders in compliance to share best practices and facilitate the alignment of systems, processes and resources.
• Participates in oversight and data review/collection related to long-term services and supports as well as coordination with local agency staff.
• Conducts Fraud, Waste and Abuse investigations, working with subcontractors as needed
• Compiles quarterly and annual Fraud, Waste and Abuse reporting Understand, analyze and communicate about key performance metrics related to social determinants of health, health disparities, housing, and cross-sector data partnerships.

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:

• Understanding of and ability to research, interpret and communicate federal and state requirements, including the Code of Federal Regulations, Oregon Revised Statutes and Administrative Rules

Core Skills and Abilities:

• Ability to perform all aspects of audit activities
• Ability to prepare clear, concise and objective audit reports with recommendations for improvement and communicate findings including performing appropriate follow-up
• Ability to develop and recommend measurement plans for improvement projects including the collection and interpretation of data
• Ability to maintain confidentiality of all discussions, records, and other data in connection with quality assurance activities
• Ability to set goals independently and prioritize work to balance competing deadlines in a professional manner, while managing multiple tasks
• Ability to use critical thinking skills in problem solving
• Ability to engage partners and facilitate consensus and collaboration among diverse stakeholders, using influencing skills when necessary
• Effective written and verbal communication skills
• Competency with computer software programs, e.g., MS Outlook, Word, Excel, and PowerPoint

Physical Skills and Abilities:

• Ability to perform repetitive finger, wrist, shoulder or neck movement for at least 6-8 hours/day
• Ability to see and read for at least 6-8 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Cognitive Skills and Abilities:

• Ability to focus on and comprehend information and learn new skills and abilities
• Ability to assess a situation and seek or determine appropriate resolution
• Ability to accept direction and feedback, as well as tolerate and manage stress

Education and/or Experience

Required:

• Minimum 4 years' experience in health care quality assurance, oversight, or a position that requires understanding and usage of relevant Medicaid laws and regulations

Preferred:

• Experience with medical, clinical, population health, claims and/or enrollment reporting and analysis

Working Conditions

Primary Work Environment:

Indoor/Office 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.

#MULTI

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.