Clinical Operations Manager - Medicare

CareOregon, Inc.; Oregon; Hybrid; USD 102,000 - 125,000; Full time

Benefits offered by this job

Competitive pay

Bonus opportunity

Benefits package

Job summary

CareOregon, Inc. in Oregon is seeking a Clinical Operations Manager - Medicare to lead the operational execution of D-SNP Model of Care programs.

You will align care management, ICTs, HRAs, and ICPs with CMS requirements to improve quality, member experience, health equity, and regulatory compliance. This role partners with Care Management, Quality, Population Health, Pharmacy, Behavioral Health, ISBI, and Compliance to deliver program performance, analytics, and continuous improvement

Qualifications

• Minimum 5 years of experience in healthcare operations, care management, population health, or quality improvement.
• Master’s degree in Healthcare Administration, Public Health, Social Work, or related healthcare field.
• Preferred: RN / RN, Certified Case Manager, or CPHQ; 3 years of Medicare Advantage, Medicaid Managed Care, SNP, or D-SNP experience.
• Minimum 2 years in a supervisory role or minimum 1 year in a supervisory role with CareOregon’s Aspiring Leaders Program.

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 CMS-approved Model of Care implementation and administration.
• Lead workflow optimization, resource utilization, and performance improvement initiatives.
• Monitor staffing models, productivity, and workload distribution.
• Monitor compliance with regulatory requirements and program goals.
• Develop and maintain operational dashboards and reports.
• Analyze clinical and operational data to identify trends and risks.
• Present results and recommendations to leadership.

Skills

Medicare Advantage

D-SNP operations

Care management

Care coordination

Data analysis

Performance metrics

Project management

Excel/Power BI/Tableau

Education

Master’s degree in Healthcare Administration

RN/CPHQ preferred

Tools

Power BI

Tableau

Microsoft Excel

Job description

Clinical Operations Manager - Medicare

The Clinical Operations Manager - Medicare is responsible for the operational execution, performance management, and continuous improvement of clinical programs that support the Dual Eligible Special Needs Plan (D-SNP) Model of Care (MOC). This role ensures that care management, care coordination, interdisciplinary care teams (ICTs), health risk assessments (HRAs), and individualized care plans (ICPs) are implemented effectively, compliantly, and consistently within Medicare. The Manager serves as a key operational leader, translating strategic clinical initiatives into day-to-day workflows that improve quality outcomes, member experience, health equity, regulatory compliance, and operational performance. This position works closely with Care Management, Quality, Population Health, Provider Relations, Pharmacy, Behavioral Health, ISBI, and Compliance teams to ensure successful deliver of D-SNP programs and services.

Estimated Hiring Range: $102,330.00 - $125,070.00

Bonus Target: Bonus - SIP Target, 5% Annual

Priority will be given to candidates residing in Oregon and Southwest Washington.

Essential Responsibilities

Care Management and Model of Care Operations

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.

Quality and Performance Management

• 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.

Analytics, Reporting, and Program Monitoring

• Develop and maintain operational dashboards and reports.
• Assist in development and maintenance of MOC 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.

Regulatory and Compliance Oversight

• 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 MOC requirements, including Health Risk Assessments (HRAs), Individualized Care Plans (ICPs), Interdisciplinary Care Team (ICT) activities, Care transition management, and Special Needs Population interventions.
• Monitor changes in regulatory guidance and support the implementation of new requirements.
• Maintain accurate records and reporting to support compliance activities.

Cross-Functional Collaboration

• 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.

Employee Supervision

• Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
• Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
• Plan, organize, schedule, and monitor work; ensure employees have 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; provide support toward employee development.
• Incorporate guidance from CareOregon 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 provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
• Perform supervisory tasks in collaboration with People and Culture as needed.

Experience and/or Education Required

• Minimum 5 years of experience in healthcare operations, care management, population health, or quality improvement.
• Master’s degree in Healthcare Administration, Public Health, Social Work, or related healthcare field.
• Preferred: Registered Nurse / RN, Certified Case Manager, or Project Management Professional Certified Professional in Healthcare Quality (CPHQ) 3 years of Medicare Advantage, Medicaid Managed Care, SNP, or D-SNP experience.
• Minimum 2 years of experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon’s Aspiring Leaders Program.

Knowledge, Skills and Abilities Required

• Knowledge: Advanced knowledge of Medicare Advantage and D-SNP operations; Advanced knowledge of CMS Model of Care requirements; Advanced knowledge of care management and care coordination practices; Knowledge of population health management principles; Knowledge of quality improvement methodologies; Advanced knowledge of healthcare regulatory and compliance standards; Advanced knowledge of health equity and social determinants of health; Knowledge of healthcare operational metrics and reporting.
• Skills and Abilities: Excellent operational planning and execution skills; Excellent project and program management skills; Excellent process improvement and workflow optimization skills; Data analysis and performance measurement skills; Audit preparation and compliance management skills; Excellent change management skills; Excellent reading, oral, and written communication; Ability to effectively collaborate with leadership and staff, and other stakeholders; Ability to utilize care management platforms and clinical documentation systems; Ability to effectively use Microsoft Excel, Power BI, Tableau, or similar reporting tools; Ability to develop Medicare reporting requirements; Ability to develop performance dashboard; Ability to work effectively with diverse individuals and groups; Ability to learn, focus, understand, and evaluate information and determine appropriate actions; Ability to accept direction and feedback, as well as tolerate and manage stress; Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours per day; Ability to hear and speak clearly for at least 3 to 6 hours per day.

Working Conditions

Work Environment(s): Indoor/Office, Community, Facilities/Security, Outdoor Exposure.

Member/Patient Facing: No, Telephonic, In Person.

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment.

Travel: 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.

Work Location: Work from home.

Total Rewards Program

• Competitive pay, bonus opportunity, and a comprehensive benefits package.
• Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours.
• Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date.
• CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.).
• We also offer a strong retirement plan with employer contributions.
• Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state.
• Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility.
• Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks.

Equal Opportunity

We are an equal opportunity employer CareOregon is an equal opportunity employer.

The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability.

The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.

CareOregon is a nonprofit, mission-driven health plan, focused on providing care to low-income Oregonians.

The CareOregon family includes Columbia Pacific CCO, Jackson Care Connect, and our work as part of Health Share of Oregon.

Our mission is to inspire and partner to create quality and equity in individual and community health.

Our vision is healthy communities for all individuals, regardless of income or social factors.

Making Healthcare Work for Absolutely Everyone.

CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.

Veterans. CareOregon greatly encourages military veterans to apply.

CareOregon is a major sponsor of the annual Portland Veterans Stand Down and hiring fair.

Ranked #8 in the Health Care Category.