Clinical Operations Manager - Medicare

Clinical Operations Manager - Medicare

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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.

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

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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/day
• Ability to hear and speak clearly for at least 3-6 hours/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

We offer a strong Total Rewards Program. This includes 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. Please contact your recruiter for more information.

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.