Senior Care Management Transformation Strategist - DSNP

Portland, Oregon

Posted in Insurance

This job has expired.

Job Info

Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

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, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

This position will take lead role the development and implementation of multi-year Care Management (CM) transformation and improvement plan in service to the out Population Health vision. This position will work closely with the CM Director as well as internal and external stakeholders (including, but not limited to, key internal teams such as Population Health, Quality Improvement, Provider Network, Compliance and Medicare/Medicaid Administration, along with providers and community partners) to develop and lead CM initiatives in accordance with CMS, OHA and NCQA requirements. This includes pursuing goals to identify evidence based best practice and elevate/scale/operationalize a standardized integrated (physical health, behavioral health, oral health) CM approach across lines of business and regions. This role requires strong and effective relationships to lead multi-stakeholder strategic planning efforts, as well as strong execution skills in order to effectuate internal and/or external work plans.

Essential Responsibilities:

  • Serve as a Care Management subject matter expert and effectively share expertise with internal stakeholders including, but not limited to Compliance, Quality Improvement, Population Health, and Provider Network.
  • Maintain knowledge and expertise in CMS and OHA regulatory requirements. Act as primary audit contact for CMS and OHA.
  • Represent the company across regions as subject matter expert and Care Management compliance and regulatory leader across Government Lines of Business's (LOB's).
  • Serve as a key subject matter expert for integrating additional regulatory/compliance requirements by identifying strategies, leading teams to build necessary work flows and ensuring required reporting capabilities are met.
  • Accountable for ensuring compliance to federal and state regulatory requirements related to Care Management across line of business, including activities performed within PacificSource and in conjunction with critical community providers.
  • Accountable for strategic development, implementation and oversight of a multi-year Government transformation and improvement strategy by leading efforts in collaboration with internal and external stakeholders such Population Health, Quality Improvement, Behavioral Health, Compliance and Provider Network along with providers and community partners.
  • Collaborate and support additional population health, clinical quality outcomes and future business opportunities to effectuate Care Management transformation strategies including new and emerging opportunities for expanded programming and services.
  • In conjunction with other subject matter experts, develop and deploy components of workforce plans, health equity plans, training plans, Transformation and Quality Strategy initiatives, and quality improvement initiatives.
  • Demonstrates strong analytical skills and ability to successfully collaborate with analytics to establish process, outcome and value metrics for clinics in integrated system of care in primary and specialty behavioral health.
  • Demonstrate ability to successfully navigate in a matrixed organization, a history of executing in a fast-paced environment, and ability to remain accountable for deliverables while working in partnership with others throughout the organization.
  • Analyze and interpret data in collaboration with other departments to identify population health cost savings and care improvement opportunities across the continuum of care and make recommendations for innovative initiatives and integrated health strategies with provider partners.
  • Actively participate in various internal and external committees in order to provide care management expertise, disseminate information, and promote BH transformation and improvement strategies.
  • Coordinate with other departments to understand and deploy needed CM clinical strategies as dictated by evidence-based criteria, legislation and parity needed.
  • Demonstrate strong communication skills (verbal and written) to ensure effective relationships and follow through.
  • Utilize Lean methodologies to identify process improvement and cultivate a culture of continuous improvement.

Supporting Responsibilities:
  • Work with department leadership in responding to inquiries or complaints to the Insurance Commission, preparing reports for other review functions, and addressing grievances and appeals.
  • Advise the Company regarding the appropriateness of reimbursement for services, considering diagnosis, and contract provisions.
  • Coordinate business activities by maintaining collaborative partnerships with key departments.
  • 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.

Work Experience: A minimum of six years clinical care/case management experience with varied health care exposure and experience. Experience within clinics and community-based settings preferred. Demonstrated knowledge and experience with program development. Demonstrated execution of complicated initiatives in a matrixed environment. Experience working within the Coordinated Care Organization environment preferred.

Education, Certificates, Licenses: Behavioral health professional with extensive experience and/or credentials, or a registered nurse with current unrestricted Oregon license and psychiatric experience is required. Bachelor degree in health services administration, social work, nursing or related field required, Master's preferred

Knowledge: Thorough knowledge and understanding of medical and behavioral procedures, diagnoses, treatment modalities, procedure codes, including ICD-9 & 10, DSM-IV & V, and CPT Codes, health insurance and mandated benefits (including those provided by a wide array of community partners) within Oregon and the Pacific Northwest. Thorough knowledge of CMS and OHA regulatory requirements. Knowledge of community services, providers, vendors and facilities available to assist members across geographic regions. Ability to use computerized systems for data and document recording and retrieval. Maintain current clinical knowledge base. Proficient in the use and implementation of the following tools and concepts across all teams within scope of accountability: Strategy Deployment, Daily Operations, Visual Management, Operational Improvement, auditing.


Building Trust

Building a Successful Team

Aligning Performance for Success

Building Partnerships

Customer Focus

Continuous Improvement

Decision Making

Facilitating Change

Leveraging Diversity

Driving for Results

Autonomous accountable work

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 15% of the time within Oregon to local CCOs and associated communities.

Accountability, Communication, 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.

This job has expired.

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